Provider Demographics
NPI:1336209139
Name:FAIRVIEW NORTHLAND
Entity Type:Organization
Organization Name:FAIRVIEW NORTHLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REHAB ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITCOMB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-389-6420
Mailing Address - Street 1:13854 RIVERVIEW DR NW
Mailing Address - Street 2:
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330-1626
Mailing Address - Country:US
Mailing Address - Phone:763-441-0487
Mailing Address - Fax:
Practice Address - Street 1:911 NORTHLAND DR
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:MN
Practice Address - Zip Code:55371-2172
Practice Address - Country:US
Practice Address - Phone:763-389-6420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4410283X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283X00000XHospitalsRehabilitation Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN=========OtherEMPLOYEE IDENTIFICATION N