# EVENTIDE FARGO LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Eventide Fargo
- **Organization subpart:** No

## Provider details

- **NPI number:** 1164809562
- **Authorized official:** MR. WADE E STUBSON (CFO)
- **Authorized official phone:** (218) 291-2216

## Contact information

- **Practice address:** 3225 51ST ST S, FARGO, ND 58104-7180
- **Practice address phone:** (218) 291-2230
- **Mailing address:** 2405 8TH ST S, SUITE A, MOORHEAD, MN 56560-4224
- **Mailing address phone:** (218) 291-2230
- **Mailing address fax:** (218) 477-3250

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 314000000X | Skilled Nursing Facility | — | NULL | Yes |

## Other

- **Enumeration date:** 05/05/2015
- **Last updated:** 08/10/2016

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 1467362 | — | ND |