MEDICARE: LAKELAND HOSPICE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency	333772	MN
2	251G00000X	Community Based Hospice Care Agency	333817	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6J75LA	OTHER	MN	HOME CARE BCBS
2	50-25406	OTHER	MN	HOSPICE MEDICA
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	59-00133	OTHER	MN	HOME CARE MEDICA
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	2Z97LA	OTHER	MN	HOSPICE BCBS

General Provider Information

NPI Number	:	1013910439
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKELAND HOSPICE, INC.

Provider Business Mailing Address
First Line	:	1505 PEBBLE LAKE RD
Second Line	:	SUITE 400
City	:	FERGUS FALLS
State	:	MN
Zip	:	56537-3858
Country	:	US
Telephone Number	:	218-998-1400
Fax Number	:	218-998-1420

Provider Business Practice Location Address
First Line	:	1505 PEBBLE LAKE RD
Second Line	:	SUITE 400
City	:	FERGUS FALLS
State	:	MN
Zip	:	56537-3858
Country	:	US
Telephone Number	:	218-998-1400
Fax Number	:	218-998-1420

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. CHERYL L PELACCIO
Credential	:
Telephone Number	:	218-998-1400

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	03/06/2009

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