Provider Demographics
NPI:1720849938
Name:WISTERIA HOME CARE
Entity Type:Organization
Organization Name:WISTERIA HOME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:
Authorized Official - Last Name:BUHENDWA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:701-793-2440
Mailing Address - Street 1:524 45TH ST S APT 202
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1009
Mailing Address - Country:US
Mailing Address - Phone:701-793-2440
Mailing Address - Fax:
Practice Address - Street 1:524 45TH ST S APT 202
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1009
Practice Address - Country:US
Practice Address - Phone:701-793-2440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health