1194885483 NPI number — CITY OF LAKE CITY

Table of content: (NPI 1194885483)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194885483 NPI number — CITY OF LAKE CITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CITY OF LAKE CITY
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:
1194885483
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 641880
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68164-7880
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-572-4019
Provider Business Mailing Address Fax Number:
402-965-8594

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
209 S HIGH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE CITY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55041-1638
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-233-5658
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SCHRECK
Authorized Official First Name:
KARI
Authorized Official Middle Name:
Authorized Official Title or Position:
CITY CLERK
Authorized Official Telephone Number:
651-345-5383

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  0126 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3416L0300X , with the licence number: 1969 , 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: 182767700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 36053LA . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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