1285695783 NPI number — LAKES REGION ARTIFICIAL LIMB AND BRACE COMPANY INC

Table of content: (NPI 1285695783)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285695783 NPI number — LAKES REGION ARTIFICIAL LIMB AND BRACE COMPANY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKES REGION ARTIFICIAL LIMB AND BRACE COMPANY 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:
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:
1285695783
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
710 VALLEY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAWLEY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56549
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-486-1963
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
710 VALLEY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAWLEY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56549
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-486-1963
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HEIDE
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
MARVIN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
218-486-1963

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 110L7RE . This is a "BLUE CROSS BLUE SHIELD MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 9150650 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 54461 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8200663 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9216690 . This is a "DAKOTA CARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 164106 . This is a "UCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 23145 . This is a "BLUE CROSS ND" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8200664 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 109L7RE . This is a "BLUE CROSS BLUE SHIELD MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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