Provider Demographics
NPI: | 1083048128 |
---|---|
Name: | LAKELAND HEALTH SERVICES, INC. |
Entity Type: | Organization |
Organization Name: | LAKELAND HEALTH SERVICES, INC. |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | GREGORY |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | SWIRTZ |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 763-354-7647 |
Mailing Address - Street 1: | 10600 OLD COUNTY ROAD 15 |
Mailing Address - Street 2: | |
Mailing Address - City: | PLYMOUTH |
Mailing Address - State: | MN |
Mailing Address - Zip Code: | 55441-6200 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 763-354-7647 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 11855 ULYSSES ST NE STE 210 |
Practice Address - Street 2: | |
Practice Address - City: | BLAINE |
Practice Address - State: | MN |
Practice Address - Zip Code: | 55434-4181 |
Practice Address - Country: | US |
Practice Address - Phone: | 763-576-9068 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2013-08-26 |
Last Update Date: | 2013-08-26 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MN | 54836 | 173F00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 173F00000X | Other Service Providers | Sleep Specialist, PhD | Group - Single Specialty |