Healthcare Provider Details

I. General information

NPI: 1164809562
Provider Name (Legal Business Name): EVENTIDE FARGO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2015
Last Update Date: 08/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3225 51ST ST S
FARGO ND
58104-7180
US

IV. Provider business mailing address

2405 8TH ST S SUITE A
MOORHEAD MN
56560-4224
US

V. Phone/Fax

Practice location:
  • Phone: 218-291-2230
  • Fax:
Mailing address:
  • Phone: 218-291-2230
  • Fax: 218-477-3250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier1467362
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer

VIII. Authorized Official

Name: MR. WADE E STUBSON
Title or Position: CFO
Credential:
Phone: 218-291-2216