Healthcare Provider Details

I. General information

NPI: 1629231121
Provider Name (Legal Business Name): MILLE LACS HEALTH SYSTEM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 04/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27378 STATE HIGHWAY 18
GARRISON MN
56450-2127
US

IV. Provider business mailing address

200 ELM ST N PO BOX A
ONAMIA MN
56359-7901
US

V. Phone/Fax

Practice location:
  • Phone: 320-692-5599
  • Fax: 320-277-3372
Mailing address:
  • Phone: 320-532-3154
  • Fax: 320-532-3111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN W UNZEN
Title or Position: CFO
Credential:
Phone: 320-532-2581