Basic Information
| Provider Information | |||||||||
| NPI: | 1922471804 | ||||||||
| 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 | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 W VERNON AVE | ||||||||
| Address2: | |||||||||
| City: | FERGUS FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565372741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187368000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2015 | ||||||||
| LastUpdateDate: | 06/05/2019 | ||||||||
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| AuthorizedOfficialLastName: | PHIBBS | ||||||||
| AuthorizedOfficialFirstName: | EDDIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2187368687 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | 1783 | MN | N | Suppliers | Eyewear Supplier (Equipment, not the service) | 332B00000X | 1783 | MN | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.