Basic Information
| Provider Information | |||||||||
| NPI: | 1093713372 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKE REGION HEALTHCARE CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 712 S CASCADE ST | ||||||||
| Address2: | |||||||||
| City: | FERGUS FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565372913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187368000 | ||||||||
| FaxNumber: | 2187368775 | ||||||||
| Practice Location | |||||||||
| Address1: | 712 S CASCADE ST | ||||||||
| Address2: | |||||||||
| City: | FERGUS FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565372913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187368000 | ||||||||
| FaxNumber: | 2187368775 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2005 | ||||||||
| LastUpdateDate: | 06/05/2019 | ||||||||
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| AuthorizedOfficialLastName: | PHIBBS | ||||||||
| AuthorizedOfficialFirstName: | EDDIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2187368000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 327293 | MN | N | Hospital Units | Psychiatric Unit | 273Y00000X | 327293 | MN | N | Hospital Units | Rehabilitation Unit | 314000000X | 327090 | MN | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 282N00000X | 327293 | MN | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 316714300 | 05 | MN | MEDICAID | 510847100 | 05 | MN | MEDICAID | 1637ELA | 01 | MN | BLUE CROSS | OTHER | 1637HLA | 01 | MN | BLUE CROSS | OTHER | 60685LA | 01 | MN | BLUE CROSS | OTHER | 510847167 | 05 | MN | MEDICAID | 510847101 | 05 | MN | MEDICAID |