Provider Demographics
NPI:1164809562
Name:EVENTIDE FARGO LLC
Entity Type:Organization
Organization Name:EVENTIDE FARGO LLC
Other - Org Name:EVENTIDE FARGO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:WADE
Authorized Official - Middle Name:E
Authorized Official - Last Name:STUBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-291-2216
Mailing Address - Street 1:2405 8TH ST S
Mailing Address - Street 2:SUITE A
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-4224
Mailing Address - Country:US
Mailing Address - Phone:218-291-2230
Mailing Address - Fax:218-477-3250
Practice Address - Street 1:3225 51ST ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-7180
Practice Address - Country:US
Practice Address - Phone:218-291-2230
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-05
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1467362Medicaid
ND1467362Medicaid