MEDICARE: TWIN LAKES PRIMARY CARE SERVICES, LLC

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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1710545264
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TWIN LAKES PRIMARY CARE SERVICES, LLC

Provider Business Mailing Address
First Line	:	20399 TURTLE RIVER LAKE RD NE
Second Line	:
City	:	HINES
State	:	MN
Zip	:	56647-5742
Country	:	US
Telephone Number	:	218-368-2093
Fax Number	:

Provider Business Practice Location Address
First Line	:	20399 TURTLE RIVER LAKE RD NE
Second Line	:
City	:	HINES
State	:	MN
Zip	:	56647-5742
Country	:	US
Telephone Number	:	218-368-2093
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PROVIDER
Name	:	JILL CEASE
Credential	:	CNP
Telephone Number	:	218-368-2093

Provider Enumeration Date	:	05/30/2019
Last Update Date	:	05/30/2019

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