Provider Demographics
NPI:1306821087
Name:SOURIS VALLEY CARE CENTER, INC.
Entity type:Organization
Organization Name:SOURIS VALLEY CARE CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO, EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:RAYE NAE
Authorized Official - Middle Name:B
Authorized Official - Last Name:NYLANDER
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:605-362-3100
Mailing Address - Street 1:300 MAIN ST S
Mailing Address - Street 2:
Mailing Address - City:VELVA
Mailing Address - State:ND
Mailing Address - Zip Code:58790-7342
Mailing Address - Country:US
Mailing Address - Phone:701-338-2072
Mailing Address - Fax:701-338-2031
Practice Address - Street 1:300 MAIN ST S
Practice Address - Street 2:
Practice Address - City:VELVA
Practice Address - State:ND
Practice Address - Zip Code:58790-7342
Practice Address - Country:US
Practice Address - Phone:701-338-2072
Practice Address - Fax:701-338-2031
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-12-14
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND025310400000X
ND1091A314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND000030216Medicaid
ND8144OtherBCBS MD- CI
ND355109Medicare ID - Type UnspecifiedMEDICARE B
ND8144OtherBCBS MD- CI