Provider Demographics
NPI:1740391853
Name:PRIDE WILTON INC.
Entity Type:Organization
Organization Name:PRIDE WILTON INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGGENBUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-258-7838
Mailing Address - Street 1:1200 MISSOURI AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-5264
Mailing Address - Country:US
Mailing Address - Phone:701-258-7838
Mailing Address - Fax:701-258-3735
Practice Address - Street 1:1200 MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-5264
Practice Address - Country:US
Practice Address - Phone:701-258-7838
Practice Address - Fax:701-258-3735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND30748Medicaid