Provider Demographics
NPI:1417124462
Name:VILLA NAZARETH
Entity Type:Organization
Organization Name:VILLA NAZARETH
Other - Org Name:FRIENDSHIP, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:
Authorized Official - Last Name:KEELER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-235-8217
Mailing Address - Street 1:801 PAGE DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2315
Mailing Address - Country:US
Mailing Address - Phone:701-235-8217
Mailing Address - Fax:701-235-7538
Practice Address - Street 1:2424 18TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-5110
Practice Address - Country:US
Practice Address - Phone:701-293-6180
Practice Address - Fax:701-232-6104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND30824315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND30824Medicaid