1043481880 NPI number — LIFTS

Table of content: (NPI 1043481880)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043481880 NPI number — LIFTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFTS
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:
6
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:
1043481880
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 166
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PINE CITY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55063-0166
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-390-8080
Provider Business Mailing Address Fax Number:
320-629-8971

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18950 HIGHWOOD SHORES RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINE CITY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55063-5409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-390-8080
Provider Business Practice Location Address Fax Number:
320-629-8971
Provider Enumeration Date:
03/20/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ISAACSON
Authorized Official First Name:
LIANE
Authorized Official Middle Name:
ELIZABETH
Authorized Official Title or Position:
OWNER/OPERATOR
Authorized Official Telephone Number:
612-390-8080

Provider Taxonomy Codes

  • Taxonomy code: 343900000X , with the licence number:  BY65152 , 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: 450060100 . This is a "MEDICAID PROVIDER NUMBER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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