Healthcare Provider Details

I. General information

NPI: 1578567996
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: 06/13/2005
Last Update Date: 04/16/2021
Certification Date: 04/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1351 BROADWAY N
FARGO ND
58102-2638
US

IV. Provider business mailing address

1351 BROADWAY N
FARGO ND
58102-2638
US

V. Phone/Fax

Practice location:
  • Phone: 701-277-7999
  • Fax: 701-277-7989
Mailing address:
  • Phone: 701-277-7999
  • Fax: 701-277-7989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1022A
License Number StateND

VII. Legacy identifiers

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

# 1
Identifier12518
Identifier TypeOTHER
Identifier StateND
Identifier IssuerBLUE CROSS ND
# 2
Identifier30420
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer
# 3
Identifier9F64R0
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerBLUE CROSS MN
# 4
Identifier687667600
Identifier TypeMEDICAID
Identifier StateMN
Identifier Issuer

VIII. Authorized Official

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