1467403030 NPI number — LAKES AREA HEALTH CENTER, PLLC

Table of content: (NPI 1467403030)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467403030 NPI number — LAKES AREA HEALTH CENTER, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKES AREA HEALTH CENTER, PLLC
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:
1467403030
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1440 DUCKWOOD DR STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAGAN
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55122-1451
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-203-4673
Provider Business Mailing Address Fax Number:
651-203-5130

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1440 DUCKWOOD DR STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAGAN
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55122-1451
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-203-4673
Provider Business Practice Location Address Fax Number:
651-203-5130
Provider Enumeration Date:
05/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PYLKAS
Authorized Official First Name:
GRANT
Authorized Official Middle Name:
Authorized Official Title or Position:
CHAIRMAN
Authorized Official Telephone Number:
651-238-5558

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 24D2153873 . This is a "CLIA" identifier . This identifiers is of the category "OTHER".




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