Provider Demographics
NPI:1003793886
Name:SPIRIT LAKE SENIOR SERVICES
Entity type:Organization
Organization Name:SPIRIT LAKE SENIOR SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JACLYN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HUNT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-766-1296
Mailing Address - Street 1:PO BOX 359
Mailing Address - Street 2:307 1ST AVE
Mailing Address - City:FORT TOTTEN
Mailing Address - State:ND
Mailing Address - Zip Code:58335
Mailing Address - Country:US
Mailing Address - Phone:701-766-1296
Mailing Address - Fax:701-766-1815
Practice Address - Street 1:307 1ST AVE
Practice Address - Street 2:
Practice Address - City:FORT TOTTEN
Practice Address - State:ND
Practice Address - Zip Code:58335
Practice Address - Country:US
Practice Address - Phone:701-766-1296
Practice Address - Fax:701-766-1815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-21
Last Update Date:2025-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1463884Medicaid