MEDICARE: CITY OF LAKE CITY

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	3416L0300X	Land Ambulance	0126	MN
2	3416L0300X	Land Ambulance	1969	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	36053LA	OTHER	MN	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1194885483
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITY OF LAKE CITY

Provider Business Mailing Address
First Line	:	PO BOX 641880
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68164-7880
Country	:	US
Telephone Number	:	402-572-4019
Fax Number	:	402-965-8594

Provider Business Practice Location Address
First Line	:	209 S HIGH ST
Second Line	:
City	:	LAKE CITY
State	:	MN
Zip	:	55041-1638
Country	:	US
Telephone Number	:	218-233-5658
Fax Number	:

Authorized Official
Title or Position	:	CITY CLERK
Name	:	KARI SCHRECK
Credential	:
Telephone Number	:	651-345-5383

Provider Enumeration Date	:	12/10/2006
Last Update Date	:	07/08/2010

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Directions to “CITY OF LAKE CITY ” Practice Location

Language	Start Address	Practice Location

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