Provider Demographics
NPI:1235210568
Name:LAKEVIEW RANCH, INC.
Entity Type:Organization
Organization Name:LAKEVIEW RANCH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
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 1:69531 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:320-275-4027
Practice Address - Fax:320-275-4028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNFBL001772920487320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0566381Medicaid