Healthcare Provider Details

I. General information

NPI: 1487251153
Provider Name (Legal Business Name): LAKE REGION CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2020
Last Update Date: 10/06/2020
Certification Date: 10/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 20TH ST NE
DEVILS LAKE ND
58301-1616
US

IV. Provider business mailing address

224 3RD ST NW
DEVILS LAKE ND
58301-2908
US

V. Phone/Fax

Practice location:
  • Phone: 701-662-8786
  • Fax:
Mailing address:
  • Phone: 701-662-8681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1455783
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer

VIII. Authorized Official

Name: SANDRA SVEDBERG
Title or Position: CFO
Credential:
Phone: 701-662-8681