Provider Demographics
NPI:1205913613
Name:WENDIGO PINES ASSISTED LIVING
Entity type:Organization
Organization Name:WENDIGO PINES ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAISA
Authorized Official - Middle Name:POVLOVNA
Authorized Official - Last Name:KOTULA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:218-326-6900
Mailing Address - Street 1:20371 WENDIGO PARK RD
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744
Mailing Address - Country:US
Mailing Address - Phone:218-326-6900
Mailing Address - Fax:218-326-6900
Practice Address - Street 1:20371 WENDIGO PARK RD
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744
Practice Address - Country:US
Practice Address - Phone:218-326-6900
Practice Address - Fax:218-326-6900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN333801310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility