Provider Demographics
NPI:1811192271
Name:PINE RIDGE RESIDENCE INC
Entity Type:Organization
Organization Name:PINE RIDGE RESIDENCE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLOOFLAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-694-6716
Mailing Address - Street 1:PO BOX 29
Mailing Address - Street 2:
Mailing Address - City:BAGLEY
Mailing Address - State:MN
Mailing Address - Zip Code:56621-0029
Mailing Address - Country:US
Mailing Address - Phone:218-694-6716
Mailing Address - Fax:218-694-3799
Practice Address - Street 1:503 HALLAN AVE
Practice Address - Street 2:
Practice Address - City:BAGLEY
Practice Address - State:MN
Practice Address - Zip Code:56621-0029
Practice Address - Country:US
Practice Address - Phone:218-694-6716
Practice Address - Fax:218-694-3799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities