Healthcare Provider Details

I. General information

NPI: 1932468683
Provider Name (Legal Business Name): LAKEWOOD HEALTH SYSTEM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2012
Last Update Date: 05/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 PRAIRIE AVE. N. 49725 CO. HWY 83
STAPLES MN
56479
US

IV. Provider business mailing address

401 PRAIRIE AVE. N. 49725 CO. HWY 83
STAPLES MN
56479
US

V. Phone/Fax

Practice location:
  • Phone: 218-894-8204
  • Fax: 218-894-8219
Mailing address:
  • Phone: 218-894-8204
  • Fax: 218-894-8219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberCC00293
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License NumberCC00293
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberCC00293
License Number StateMN

VIII. Authorized Official

Name: NANCY J RACH
Title or Position: COUNSELOR
Credential: MS
Phone: 218-640-1992