Healthcare Provider Details

I. General information

NPI: 1710127139
Provider Name (Legal Business Name): CITY OF MINNESOTA LAKE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2009
Last Update Date: 04/22/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 LAKE AVE E #01
MINNESOTA LAKE MN
56068-7511
US

IV. Provider business mailing address

103 MAIN ST. N PO BOX 98
MINNESOTA LAKE MN
56068-0098
US

V. Phone/Fax

Practice location:
  • Phone: 507-462-3277
  • Fax: 507-462-3438
Mailing address:
  • Phone: 507-462-3277
  • Fax: 507-462-3438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code341600000X
TaxonomyAmbulance
License Number0163
License Number StateMN

VIII. Authorized Official

Name: DAVID RADTKE
Title or Position: DIRECTOR
Credential:
Phone: 507-381-7696