Healthcare Provider Details

I. General information

NPI: 1053316497
Provider Name (Legal Business Name): SISTERS OF MARY OF THE PRESENTATION LONG TERM CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 04/16/2021
Certification Date: 04/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3102 S UNIVERSITY DRIVE
FARGO ND
58103
US

IV. Provider business mailing address

3102 S UNIVERSITY DRIVE
FARGO ND
58103
US

V. Phone/Fax

Practice location:
  • Phone: 701-293-7750
  • Fax: 701-293-5845
Mailing address:
  • Phone: 701-293-7750
  • Fax: 701-293-5845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1023B
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier030419
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer

VIII. Authorized Official

Name: MELDINE KAY TANG
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 701-277-7999