1720163207 NPI number — MILLE LACS HEALTH SYSTEM

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 1720163207 NPI number — MILLE LACS HEALTH SYSTEM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MILLE LACS HEALTH SYSTEM
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:
1720163207
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/18/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ONAMIA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56359-0807
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-532-2490
Provider Business Mailing Address Fax Number:
320-532-2499

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 ELM ST N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ONAMIA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56359-7901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-532-2490
Provider Business Practice Location Address Fax Number:
320-532-2499
Provider Enumeration Date:
10/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STEFFENSON
Authorized Official First Name:
GREG
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACIST
Authorized Official Telephone Number:
320-532-2490

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336I0012X , with the licence number: 2010470 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2045656 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 190247400 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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