Provider Demographics
NPI:1487705653
Name:EVENTIDE
Entity type:Organization
Organization Name:EVENTIDE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:WADE
Authorized Official - Middle Name:E
Authorized Official - Last Name:STUBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-291-2216
Mailing Address - Street 1:1405 7TH ST S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-3444
Mailing Address - Country:US
Mailing Address - Phone:218-233-7508
Mailing Address - Fax:218-233-3602
Practice Address - Street 1:1405 7TH ST S
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-3444
Practice Address - Country:US
Practice Address - Phone:218-233-7508
Practice Address - Fax:218-233-3602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN00072314000000X
MN332819310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Not Answered310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
245461Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID