1073703690 NPI number — MRS. LACEY LYNN OPPERUD KONICKSON MOT

Table of content: MRS. LACEY LYNN OPPERUD KONICKSON MOT (NPI 1073703690)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073703690 NPI number — MRS. LACEY LYNN OPPERUD KONICKSON MOT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KONICKSON
Provider First Name:
LACEY
Provider Middle Name:
LYNN OPPERUD
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MOT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PAHLEN
Provider Other First Name:
LACEY
Provider Other Middle Name:
LYNN OPPERUD
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
MOT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1073703690
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5074
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57117-5074
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-328-9419
Provider Business Mailing Address Fax Number:
701-780-1942

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3001 SANFORD PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
THIEF RIVER FALLS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56701-2700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-780-5000
Provider Business Practice Location Address Fax Number:
701-780-1942
Provider Enumeration Date:
07/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  103465 , 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)





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