Basic Information
Provider Information | |||||||||
NPI: | 1316279227 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LSREF GOLDEN OPS 14 (WY) LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PARK PLACE ASSISTED LIVING | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3015 16TH ST SW | ||||||||
Address2: | STE 100 | ||||||||
City: | MINOT | ||||||||
State: | ND | ||||||||
PostalCode: | 587016906 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7018377103 | ||||||||
FaxNumber: | 7018387785 | ||||||||
Practice Location | |||||||||
Address1: | 1930 E 12TH ST | ||||||||
Address2: |   | ||||||||
City: | CASPER | ||||||||
State: | WY | ||||||||
PostalCode: | 826014075 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3072652273 | ||||||||
FaxNumber: | 3072655384 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/02/2010 | ||||||||
LastUpdateDate: | 02/02/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WENTZ | ||||||||
AuthorizedOfficialFirstName: | TOM | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXEC. VP/COO | ||||||||
AuthorizedOfficialTelephone: | 7018377103 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 10200 | WY | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   |
No ID Information.