Provider Demographics
NPI:1073755385
Name:LAKEVIEW RANCH HEALTHCARE LLC
Entity Type:Organization
Organization Name:LAKEVIEW RANCH HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-275-4027
Mailing Address - Street 1:69531 213TH ST
Mailing Address - Street 2:
Mailing Address - City:DARWIN
Mailing Address - State:MN
Mailing Address - Zip Code:55324-6602
Mailing Address - Country:US
Mailing Address - Phone:320-275-4611
Mailing Address - Fax:320-275-4030
Practice Address - Street 1:69531 213TH ST
Practice Address - Street 2:
Practice Address - City:DARWIN
Practice Address - State:MN
Practice Address - Zip Code:55324-6602
Practice Address - Country:US
Practice Address - Phone:320-275-4611
Practice Address - Fax:320-275-4030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNM124983000Medicaid