MEDICARE: LAKEVILLE INTEGRATIVE MEDICINE CLINIC

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	261QM2500X	Medical Specialty Clinic/Center	31345	MN

General Provider Information

NPI Number	:	1851425227
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKEVILLE INTEGRATIVE MEDICINE CLINIC

Provider Business Mailing Address
First Line	:	16372 KENRICK AVE
Second Line	:	SUITE 100
City	:	LAKEVILLE
State	:	MN
Zip	:	55044-3540
Country	:	US
Telephone Number	:	952-892-6700
Fax Number	:	952-892-9475

Provider Business Practice Location Address
First Line	:	16372 KENRICK AVE
Second Line	:	SUITE 100
City	:	LAKEVILLE
State	:	MN
Zip	:	55044-3540
Country	:	US
Telephone Number	:	952-892-6700
Fax Number	:	952-892-9475

Authorized Official
Title or Position	:	CEO
Name	:	DR. MARK D RIEB
Credential	:	MD, NMD
Telephone Number	:	952-892-6700

Provider Enumeration Date	:	03/15/2007
Last Update Date	:	08/22/2020

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