Provider Demographics
NPI:1407984081
Name:EVENTIDE SENIOR LIVING COMMUNITIES LLC
Entity Type:Organization
Organization Name:EVENTIDE SENIOR LIVING COMMUNITIES LLC
Other - Org Name:
Other - Org Type:
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:2182-912-2216
Mailing Address - Street 1:1405 7TH ST S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-3444
Mailing Address - Country:US
Mailing Address - Phone:218-233-7508
Mailing Address - Fax:
Practice Address - Street 1:225 13TH AVENUE WEST
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078
Practice Address - Country:US
Practice Address - Phone:701-478-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND63310400000X
ND8100A311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Not Answered311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)