Healthcare Provider Details

I. General information

NPI: 1235299066
Provider Name (Legal Business Name): CITY OF MOUNTAIN LAKE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 11TH AVENUE
MOUNTAIN LAKE MN
56159
US

IV. Provider business mailing address

PO BOX C
MOUNTAIN LAKE MN
56159-0320
US

V. Phone/Fax

Practice location:
  • Phone: 218-233-5658
  • Fax:
Mailing address:
  • Phone: 218-233-5658
  • Fax: 218-233-7630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number0171
License Number StateMN

VIII. Authorized Official

Name: DEAN JANZEN
Title or Position: MAYOR
Credential:
Phone: 507-427-2999