Provider Demographics
NPI:1225437460
Name:NEW TOWN HEALTH SUPPORT CORPORATION
Entity Type:Organization
Organization Name:NEW TOWN HEALTH SUPPORT CORPORATION
Other - Org Name:LAKESIDE COMMUNITY LIVING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JEANINE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:URAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-627-4711
Mailing Address - Street 1:PO BOX 818
Mailing Address - Street 2:
Mailing Address - City:NEW TOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58763
Mailing Address - Country:US
Mailing Address - Phone:701-627-4711
Mailing Address - Fax:701-627-4013
Practice Address - Street 1:603 1ST STREET NW
Practice Address - Street 2:
Practice Address - City:NEW TOWN
Practice Address - State:ND
Practice Address - Zip Code:58763
Practice Address - Country:US
Practice Address - Phone:701-627-4711
Practice Address - Fax:701-627-4013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-13
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND8088310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND030792Medicaid