Basic Information
| Provider Information | |||||||||
| NPI: | 1588761993 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SANFORD LIVING CENTERS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | SANFORD HEALTH UNDERWOOD CONTINUING CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 18TH ST NW | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | MANDAN | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585541612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013236000 | ||||||||
| FaxNumber: | 7013235221 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 18TH ST NW | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | MANDAN | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585541612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013236000 | ||||||||
| FaxNumber: | 7013235221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 05/15/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RIEKE | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 7013238180 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1062B | ND | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 30053 | 05 | ND | MEDICAID | 1305 | 01 | BCBS | OTHER | 1062B | 01 | ND | STATE | OTHER |