Healthcare Provider Details

I. General information

NPI: 1588761993
Provider Name (Legal Business Name): SANFORD LIVING CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 05/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 18TH ST NW SUITE 1
MANDAN ND
58554-1612
US

IV. Provider business mailing address

1000 18TH ST NW SUITE 1
MANDAN ND
58554-1612
US

V. Phone/Fax

Practice location:
  • Phone: 701-323-6000
  • Fax: 701-323-5221
Mailing address:
  • Phone: 701-323-6000
  • Fax: 701-323-5221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1062B
License Number StateND

VII. Legacy identifiers

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

# 1
Identifier30053
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer
# 2
Identifier1305
Identifier TypeOTHER
Identifier State
Identifier IssuerBCBS
# 3
Identifier1062B
Identifier TypeOTHER
Identifier StateND
Identifier IssuerSTATE

VIII. Authorized Official

Name: MR. JOHN B RIEKE
Title or Position: COO
Credential:
Phone: 701-323-8180