Provider Demographics
NPI:1962013847
Name:WILD RIVER SERVICES INC
Entity Type:Organization
Organization Name:WILD RIVER SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:COLIN
Authorized Official - Middle Name:KELLY
Authorized Official - Last Name:FAULKNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-558-9522
Mailing Address - Street 1:1394 JACKSON ST STE 220
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-4631
Mailing Address - Country:US
Mailing Address - Phone:651-558-9522
Mailing Address - Fax:
Practice Address - Street 1:1394 JACKSON ST STE 220
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55117-4631
Practice Address - Country:US
Practice Address - Phone:651-558-9522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care