Healthcare Provider Details

I. General information

NPI: 1871718213
Provider Name (Legal Business Name): CASS LAKE INDIAN HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 7TH ST NW
CASS LAKE MN
56633-3360
US

IV. Provider business mailing address

45587 US 71
LAPORTE MN
56461-4900
US

V. Phone/Fax

Practice location:
  • Phone: 218-335-3200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number
License Number State

VIII. Authorized Official

Name: MRS. TAWNYA MARIE JENSEN
Title or Position: MLT
Credential:
Phone: 218-335-3200