Healthcare Provider Details

I. General information

NPI: 1801229000
Provider Name (Legal Business Name): LONGVILLE LAKES CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2013
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13205 ISLE DRIVE
BAXTER MN
56425
US

IV. Provider business mailing address

320 E MAIN ST
CROSBY MN
56441-1645
US

V. Phone/Fax

Practice location:
  • Phone: 218-546-7000
  • Fax: 218-546-4645
Mailing address:
  • Phone: 218-546-7000
  • Fax: 218-546-4645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KATIE BERG
Title or Position: CFO
Credential:
Phone: 218-546-7000