Basic Information
| Provider Information | |||||||||
| NPI: | 1932163904 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKES REGIONAL HEALTHCARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX AB | ||||||||
| Address2: | |||||||||
| City: | SPIRIT LAKE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 513600159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7123361230 | ||||||||
| FaxNumber: | 7123389990 | ||||||||
| Practice Location | |||||||||
| Address1: | 2301 HIGHWAY 71 | ||||||||
| Address2: | |||||||||
| City: | SPIRIT LAKE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 51360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7123361230 | ||||||||
| FaxNumber: | 7123389990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 09/07/2018 | ||||||||
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| AuthorizedOfficialLastName: | ALGER | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | SR VP AND CFO | ||||||||
| AuthorizedOfficialTelephone: | 7123368796 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 300028H | IA | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 0671388 | 05 | IA | MEDICAID |