Healthcare Provider Details

I. General information

NPI: 1962013847
Provider Name (Legal Business Name): WILD RIVER SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2020
Last Update Date: 08/13/2020
Certification Date: 08/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1394 JACKSON ST STE 220
SAINT PAUL MN
55117-4631
US

IV. Provider business mailing address

1394 JACKSON ST STE 220
SAINT PAUL MN
55117-4631
US

V. Phone/Fax

Practice location:
  • Phone: 651-558-9522
  • Fax:
Mailing address:
  • Phone: 651-558-9522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: COLIN KELLY FAULKNER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 651-558-9522