=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710127139
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CITY OF MINNESOTA LAKE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2009
-----------------------------------------------------
Last Update Date | 04/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 LAKE AVE E #01
-----------------------------------------------------
City | MINNESOTA LAKE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56068-7511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-462-3277
-----------------------------------------------------
Fax | 507-462-3438
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 103 MAIN ST. N PO BOX 98
-----------------------------------------------------
City | MINNESOTA LAKE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56068-0098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-462-3277
-----------------------------------------------------
Fax | 507-462-3438
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DAVID RADTKE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 507-381-7696
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 341600000X
-----------------------------------------------------
Taxonomy Name | Ambulance
-----------------------------------------------------
License Number | 0163
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------