Provider Demographics
NPI:1861745838
Name:BENEDICTINE LIVING COMMUNITY OF WAHPETON
Entity type:Organization
Organization Name:BENEDICTINE LIVING COMMUNITY OF WAHPETON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/CEO
Authorized Official - Prefix:
Authorized Official - First Name:EMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:TRETTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-642-6667
Mailing Address - Street 1:711 14TH AVENUE NORTH
Mailing Address - Street 2:
Mailing Address - City:WAHPETON
Mailing Address - State:ND
Mailing Address - Zip Code:58075
Mailing Address - Country:US
Mailing Address - Phone:701-642-6667
Mailing Address - Fax:
Practice Address - Street 1:711 14TH AVENUE NORTH
Practice Address - Street 2:
Practice Address - City:WAHPETON
Practice Address - State:ND
Practice Address - Zip Code:58075
Practice Address - Country:US
Practice Address - Phone:701-642-6667
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BENEDICTINE LIVING COMMUNITIES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-16
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDAPPLIED FORMedicaid