Healthcare Provider Details

I. General information

NPI: 1437182839
Provider Name (Legal Business Name): LAKES IMAGING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2019 S 6TH ST
BRAINERD MN
56401-4528
US

IV. Provider business mailing address

2019 S 6TH ST
BRAINERD MN
56401-4528
US

V. Phone/Fax

Practice location:
  • Phone: 218-822-4242
  • Fax: 218-822-3758
Mailing address:
  • Phone: 218-822-4242
  • Fax: 218-822-3758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number StateMN

VIII. Authorized Official

Name: JOHN HOLMEN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 218-822-4242