Provider Demographics
NPI:1083942221
Name:LAKEVIEW RANCH INC.
Entity Type:Organization
Organization Name:LAKEVIEW RANCH INC.
Other - Org Name:LAKEVIEW RANCH DASSEL
Other - Org Type:Other Name
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:320-275-4027
Mailing Address - Fax:320-275-4028
Practice Address - Street 1:22851 MN HIGHWAY 15
Practice Address - Street 2:
Practice Address - City:DASSEL
Practice Address - State:MN
Practice Address - Zip Code:55325-3568
Practice Address - Country:US
Practice Address - Phone:320-275-5515
Practice Address - Fax:320-275-5516
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKEVIEW RANCH INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-11-30
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN342097311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN050513016Medicaid