Healthcare Provider Details

I. General information

NPI: 1023651916
Provider Name (Legal Business Name): LAKEWALK SURGERY CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2019
Last Update Date: 10/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 LONDON RD STE 100
DULUTH MN
55805-2437
US

IV. Provider business mailing address

1420 LONDON RD STE 100
DULUTH MN
55805-2437
US

V. Phone/Fax

Practice location:
  • Phone: 218-728-8505
  • Fax:
Mailing address:
  • Phone: 218-728-8505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANN MARIE FOSNESS
Title or Position: ADMINISTRATOR
Credential: RN
Phone: 218-728-8505