Healthcare Provider Details

I. General information

NPI: 1689667834
Provider Name (Legal Business Name): LAKE REGION LUTHERAN HOME, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 07/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 14TH AVE NE
DEVILS LAKE ND
58301-2808
US

IV. Provider business mailing address

620 14TH AVE NE
DEVILS LAKE ND
58301-2808
US

V. Phone/Fax

Practice location:
  • Phone: 701-662-4905
  • Fax: 701-662-9170
Mailing address:
  • Phone: 701-662-4905
  • Fax: 701-662-9170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number1013A
License Number StateND

VIII. Authorized Official

Name: MRS. KARISSA OLSON
Title or Position: CEO
Credential: LNHA
Phone: 701-662-4905