1023067642 NPI number — LAKE VIEW MEMORIAL HOSPITAL, INCORPORATED

Table of content: (NPI 1023067642)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023067642 NPI number — LAKE VIEW MEMORIAL HOSPITAL, INCORPORATED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE VIEW MEMORIAL HOSPITAL, INCORPORATED
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023067642
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
325 11TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TWO HARBORS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55616-1300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-834-7300
Provider Business Mailing Address Fax Number:
218-834-7388

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
325 11TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TWO HARBORS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-834-7300
Provider Business Practice Location Address Fax Number:
218-834-7388
Provider Enumeration Date:
05/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RUBERG
Authorized Official First Name:
GREG
Authorized Official Middle Name:
GARRETT
Authorized Official Title or Position:
PRESIDENT / CEO
Authorized Official Telephone Number:
218-834-7345

Provider Taxonomy Codes

  • Taxonomy code: 282NC0060X , with the licence number:  331064 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2718 . This is a "HEALTHPARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 739045900 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01016526 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: UCARE . This is a "UCARE MINNESOTA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1886HLA . This is a "BLUE CROSS MINNESOTA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 5000116 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com