MEDICARE: LAKE REGION HALFWAY HOMES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	324500000X	Substance Abuse Rehabilitation Facility	801334-2-CDT	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	726555700	OTHER	MN	MHCP PROVIDER NUMBER

General Provider Information

NPI Number	:	1851455323
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE REGION HALFWAY HOMES, INC.

Provider Business Mailing Address
First Line	:	217 N UNION AVE
Second Line	:
City	:	FERGUS FALLS
State	:	MN
Zip	:	56537-2127
Country	:	US
Telephone Number	:	218-739-9084
Fax Number	:	218-739-0518

Provider Business Practice Location Address
First Line	:	217 N UNION AVE
Second Line	:
City	:	FERGUS FALLS
State	:	MN
Zip	:	56537-2127
Country	:	US
Telephone Number	:	218-739-9084
Fax Number	:	218-739-0518

Authorized Official
Title or Position	:	TREATMENT DIRECTOR
Name	:	MS. SHERRI E. CLARK
Credential	:	LADC
Telephone Number	:	218-739-9084

Provider Enumeration Date	:	12/20/2006
Last Update Date	:	09/10/2009

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Directions to “LAKE REGION HALFWAY HOMES, INC. ” Practice Location

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