Basic Information
| Provider Information | |||||||||
| NPI: | 1801292685 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKES REGIONAL HEALTHCARE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 400 E 10TH ST | ||||||||
| Address2: | |||||||||
| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553874552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524429770 | ||||||||
| FaxNumber: | 9524423620 | ||||||||
| Practice Location | |||||||||
| Address1: | 2301 HIGHWAY 71 SOUTH | ||||||||
| Address2: | |||||||||
| City: | SPIRIT LAKE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 51360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7123361230 | ||||||||
| FaxNumber: | 7123368634 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2014 | ||||||||
| LastUpdateDate: | 09/07/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALGER | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | JAMES | ||||||||
| AuthorizedOfficialTitleorPosition: | SR VP AND CFO | ||||||||
| AuthorizedOfficialTelephone: | 7123368796 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 300028H | IA | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.