=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538100920
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKEWIND, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1624 JEFFERSON ST
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55812-1613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-728-2209
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1624 JEFFERSON ST
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55812-1613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JACQUELINE NELOSN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 218-728-2209
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251K00000X
-----------------------------------------------------
Taxonomy Name | Public Health or Welfare Agency
-----------------------------------------------------
License Number | 810357
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------