Healthcare Provider Details

I. General information

NPI: 1922471804
Provider Name (Legal Business Name): LAKE REGION HEALTHCARE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2015
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W VERNON AVE
FERGUS FALLS MN
56537-2741
US

IV. Provider business mailing address

712 S CASCADE ST
FERGUS FALLS MN
56537-2913
US

V. Phone/Fax

Practice location:
  • Phone: 218-736-8000
  • Fax:
Mailing address:
  • Phone: 218-736-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number1783
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number1783
License Number StateMN

VIII. Authorized Official

Name: KENT MATTSON
Title or Position: CEO
Credential:
Phone: 218-736-8090