Healthcare Provider Details

I. General information

NPI: 1316948631
Provider Name (Legal Business Name): MARIAN MANOR COMMUNITY CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 12/17/2019
Certification Date: 12/17/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 E ASH AVE
GLEN ULLIN ND
58631-7138
US

IV. Provider business mailing address

PO BOX 578
GLEN ULLIN ND
58631-0578
US

V. Phone/Fax

Practice location:
  • Phone: 701-348-3107
  • Fax:
Mailing address:
  • Phone: 701-348-3107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1025A
License Number StateND

VIII. Authorized Official

Name: MS. SANDRA F GERVING
Title or Position: ADMINISTRATOR
Credential:
Phone: 701-348-3107