Provider Demographics
NPI:1770552820
Name:BENEDICTINE LIVING COMMUNITIES, INC.
Entity type:Organization
Organization Name:BENEDICTINE LIVING COMMUNITIES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:CORNELIUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-642-6667
Mailing Address - Street 1:1307 7TH ST N
Mailing Address - Street 2:
Mailing Address - City:WAHPETON
Mailing Address - State:ND
Mailing Address - Zip Code:58075-3624
Mailing Address - Country:US
Mailing Address - Phone:701-642-6667
Mailing Address - Fax:701-642-2485
Practice Address - Street 1:1307 7TH ST N
Practice Address - Street 2:
Practice Address - City:WAHPETON
Practice Address - State:ND
Practice Address - Zip Code:58075-3624
Practice Address - Country:US
Practice Address - Phone:701-642-6667
Practice Address - Fax:701-642-2485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4065A251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND10272OtherBLUE CROSS BLUE SHIELD
MN596317600Medicaid
MN3P6OCAOtherBLUE PLUS
ND50677Medicaid
ND50677Medicaid