Provider Demographics
NPI:1790851863
Name:AMHERST H. WILDER FOUNDATION
Entity Type:Organization
Organization Name:AMHERST H. WILDER FOUNDATION
Other - Org Name:WILDER ADULT DAY HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIVISION DIRECTOR, CSE
Authorized Official - Prefix:
Authorized Official - First Name:LENI
Authorized Official - Middle Name:G
Authorized Official - Last Name:WILCOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-280-2500
Mailing Address - Street 1:650 MARSHALL AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-6644
Mailing Address - Country:US
Mailing Address - Phone:651-280-2500
Mailing Address - Fax:651-224-6906
Practice Address - Street 1:753 7TH ST E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-5025
Practice Address - Country:US
Practice Address - Phone:651-280-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN369223000OtherMEDICAL ASSISTANCE
MN116579Medicare UPIN
MN21626Medicare UPIN
MN4981518Medicare UPIN