Healthcare Provider Details

I. General information

NPI: 1497917587
Provider Name (Legal Business Name): MILLE LACS HEALTH SYSTEM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2008
Last Update Date: 05/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 W ISLE ST
ISLE MN
56342-2640
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 320-676-3661
  • Fax: 320-676-4011
Mailing address:
  • Phone: 320-532-3154
  • Fax: 320-532-3111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

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