Provider Demographics
NPI:1275627184
Name:4000 VALLEY SQUARE INC
Entity Type:Organization
Organization Name:4000 VALLEY SQUARE INC
Other - Org Name:COUNTRY ESTATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATIVE PROJECT COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-787-7970
Mailing Address - Street 1:4000 24TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-8863
Mailing Address - Country:US
Mailing Address - Phone:701-787-7500
Mailing Address - Fax:701-787-7822
Practice Address - Street 1:4000 24TH AVE S
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-8863
Practice Address - Country:US
Practice Address - Phone:701-787-7500
Practice Address - Fax:701-787-7822
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VALLEY MEMORIAL HOMES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-03
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1077A314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND03-0201Medicaid
ND03-0201Medicaid