1093713372 NPI number — LAKE REGION HEALTHCARE CORPORATION

Table of content: (NPI 1093713372)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093713372 NPI number — LAKE REGION HEALTHCARE CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE REGION HEALTHCARE CORPORATION
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:
1093713372
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
712 S CASCADE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FERGUS FALLS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56537-2913
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-736-8000
Provider Business Mailing Address Fax Number:
218-736-8775

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
712 S CASCADE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FERGUS FALLS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56537-2913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-736-8000
Provider Business Practice Location Address Fax Number:
218-736-8775
Provider Enumeration Date:
07/12/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MATTSON
Authorized Official First Name:
KENT
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
218-736-8090

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  327293 , 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: 1637HLA . This is a "BLUE CROSS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 316714300 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 510847101 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 510847167 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1637ELA . This is a "BLUE CROSS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 60685LA . This is a "BLUE CROSS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 510847100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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