1083942221 NPI number — LAKEVIEW RANCH INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083942221 NPI number — LAKEVIEW RANCH INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKEVIEW RANCH INC.
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:
1083942221
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
69531 213TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DARWIN
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55324-6602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-275-4027
Provider Business Mailing Address Fax Number:
320-275-4028

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22851 MN HIGHWAY 15
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DASSEL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55325-3568
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-275-5515
Provider Business Practice Location Address Fax Number:
320-275-5516
Provider Enumeration Date:
11/30/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BERRY
Authorized Official First Name:
JUDY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
320-275-4027

Provider Taxonomy Codes

  • Taxonomy code: 311500000X , with the licence number:  342097 , 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: 050513016 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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