MEDICARE: LAKE REGION LUTHERAN HOME, 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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1619536976
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE REGION LUTHERAN HOME, INC.

Provider Business Mailing Address
First Line	:	801 MAIN AVE STE 201
Second Line	:
City	:	MOORHEAD
State	:	MN
Zip	:	56560-2871
Country	:	US
Telephone Number	:	218-291-2216
Fax Number	:

Provider Business Practice Location Address
First Line	:	1332 10TH ST NE
Second Line	:
City	:	DEVILS LAKE
State	:	ND
Zip	:	58301-2329
Country	:	US
Telephone Number	:	701-662-1880
Fax Number	:	701-662-1084

Authorized Official
Title or Position	:	PRESIDENT & CEO
Name	:	JON RIEWER
Credential	:
Telephone Number	:	218-291-2201

Provider Enumeration Date	:	06/11/2019
Last Update Date	:	06/11/2019

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