Wendigo Pines Assisted Living

Primary specialty

Assisted Living FacilityTaxonomy code 310400000X

License

333801 Issued in MN

Legal business name

WENDIGO PINES ASSISTED LIVING

Practice address

20371 Wendigo Park Rd
Grand Rapids, MN 55744

Phone

(218) 326-6900

Fax

(218) 326-6900

NPI assigned

Nov 1, 2006

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Raisa Povlovna Kotula, RN

Title

RN Owner

Phone

(218) 326-6900

Specialties & licenses 1

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1162339200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1205913613",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "20371 WENDIGO PARK RD",
            "city": "GRAND RAPIDS",
            "state": "MN",
            "postal_code": "55744",
            "telephone_number": "218-326-6900",
            "fax_number": "218-326-6900"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "20371 WENDIGO PARK RD",
            "city": "GRAND RAPIDS",
            "state": "MN",
            "postal_code": "55744",
            "telephone_number": "218-326-6900",
            "fax_number": "218-326-6900"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WENDIGO PINES ASSISTED LIVING",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-01",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "KOTULA",
        "authorized_official_first_name": "RAISA",
        "authorized_official_middle_name": "POVLOVNA",
        "authorized_official_title_or_position": "RN OWNER",
        "authorized_official_telephone_number": "218-326-6900",
        "authorized_official_credential": "RN"
    },
    "taxonomies": [
        {
            "code": "310400000X",
            "taxonomy_group": "",
            "desc": "Assisted Living Facility",
            "state": "MN",
            "license": "333801",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.