Provider Demographics
NPI:1033321351
Name:LIVING SERVICES FOUNDATION/ NEW LONDON LLC
Entity Type:Organization
Organization Name:LIVING SERVICES FOUNDATION/ NEW LONDON LLC
Other - Org Name:LAKE REGION HOME HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:LAINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-354-6057
Mailing Address - Street 1:100 GLEN OAKS DR
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:MN
Mailing Address - Zip Code:56273
Mailing Address - Country:US
Mailing Address - Phone:320-354-6068
Mailing Address - Fax:320-354-2060
Practice Address - Street 1:102 GLEN OAKS DR
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:MN
Practice Address - Zip Code:56273
Practice Address - Country:US
Practice Address - Phone:320-354-5858
Practice Address - Fax:320-354-2060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNHFID - 02204251E00000X
MN345647310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN498454400Medicaid
MN498454400Medicaid