Provider Demographics
NPI:1073683017
Name:LAKE COUNTY AMBULANCE
Entity Type:Organization
Organization Name:LAKE COUNTY AMBULANCE
Other - Org Name:SILVER BAY AMBULANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-834-7110
Mailing Address - Street 1:421 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:TWO HARBORS
Mailing Address - State:MN
Mailing Address - Zip Code:55616-1364
Mailing Address - Country:US
Mailing Address - Phone:218-834-7110
Mailing Address - Fax:
Practice Address - Street 1:87 BANKS BLVD.
Practice Address - Street 2:
Practice Address - City:SILVER BAY
Practice Address - State:MN
Practice Address - Zip Code:55614-0066
Practice Address - Country:US
Practice Address - Phone:218-226-4423
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN02303416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5G890TWOtherBCBS OF MN
MN59000035Medicare ID - Type UnspecifiedMEDICARE