Provider Demographics
NPI:1699927897
Name:NORTHLAND PACE PROGRAM
Entity type:Organization
Organization Name:NORTHLAND PACE PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RODGER
Authorized Official - Middle Name:
Authorized Official - Last Name:WETZEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-751-3050
Mailing Address - Street 1:201 N 24TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501
Mailing Address - Country:US
Mailing Address - Phone:701-751-3050
Mailing Address - Fax:701-751-3053
Practice Address - Street 1:201 N 24TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501
Practice Address - Country:US
Practice Address - Phone:701-751-3050
Practice Address - Fax:701-751-3053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
H7195251T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization