Provider Demographics
NPI:1063834778
Name:LAKE REGION HOME MEDICAL, LLC
Entity Type:Organization
Organization Name:LAKE REGION HOME MEDICAL, LLC
Other - Org Name:CORNER HOME MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMI
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BAGSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-540-6119
Mailing Address - Street 1:2730 NEVADA AVE N
Mailing Address - Street 2:
Mailing Address - City:NEW HOPE
Mailing Address - State:MN
Mailing Address - Zip Code:55427-2807
Mailing Address - Country:US
Mailing Address - Phone:637-535-5335
Mailing Address - Fax:
Practice Address - Street 1:1432 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-1032
Practice Address - Country:US
Practice Address - Phone:320-263-1349
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-15
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies