Healthcare Provider Details

I. General information

NPI: 1457910713
Provider Name (Legal Business Name): LAKE REGION LUTHERAN HOME, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 7TH AVE NE
DEVILS LAKE ND
58301-2516
US

IV. Provider business mailing address

801 MAIN AVE STE 201
MOORHEAD MN
56560-2871
US

V. Phone/Fax

Practice location:
  • Phone: 701-662-6580
  • Fax: 701-662-4030
Mailing address:
  • Phone: 218-291-2230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: JON RIEWER
Title or Position: PRESIDENT & CEO
Credential:
Phone: 218-291-2201