Provider Demographics
NPI:1487658324
Name:PARKSIDE HOME
Entity Type:Organization
Organization Name:PARKSIDE HOME
Other - Org Name:PARKSIDE LUTHERAN HOME, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDRICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-683-5239
Mailing Address - Street 1:501 - 3RD AVE WEST
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:ND
Mailing Address - Zip Code:58054-0153
Mailing Address - Country:US
Mailing Address - Phone:701-683-5239
Mailing Address - Fax:701-683-4109
Practice Address - Street 1:501 - 3RD AVE WEST
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:ND
Practice Address - Zip Code:58054-0153
Practice Address - Country:US
Practice Address - Phone:701-683-5239
Practice Address - Fax:701-683-4109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-09
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1081A314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND355116Medicare ID - Type Unspecified