Provider Demographics
NPI:1861470429
Name:FOUR SEASONS HEALTHCARE CENTER INC
Entity Type:Organization
Organization Name:FOUR SEASONS HEALTHCARE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEDE
Authorized Official - Middle Name:
Authorized Official - Last Name:COOKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-724-6211
Mailing Address - Street 1:483 4TH ST SW
Mailing Address - Street 2:
Mailing Address - City:FORMAN
Mailing Address - State:ND
Mailing Address - Zip Code:58032-4210
Mailing Address - Country:US
Mailing Address - Phone:701-724-6211
Mailing Address - Fax:701-724-3060
Practice Address - Street 1:483 4TH ST SW
Practice Address - Street 2:
Practice Address - City:FORMAN
Practice Address - State:ND
Practice Address - Zip Code:58032-4210
Practice Address - Country:US
Practice Address - Phone:701-724-6211
Practice Address - Fax:701-724-3060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-04
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND8070A313M00000X
ND1075B314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
30762OtherBASIC CARE
ND30406Medicaid
30762OtherBASIC CARE