Provider Demographics
NPI:1235299066
Name:CITY OF MOUNTAIN LAKE
Entity Type:Organization
Organization Name:CITY OF MOUNTAIN LAKE
Other - Org Name:MOUNTAIN LAKE AMBULANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MAYOR
Authorized Official - Prefix:
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JANZEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-427-2999
Mailing Address - Street 1:PO BOX C
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56159-0320
Mailing Address - Country:US
Mailing Address - Phone:218-233-5658
Mailing Address - Fax:218-233-7630
Practice Address - Street 1:1100 11TH AVENUE
Practice Address - Street 2:
Practice Address - City:MOUNTAIN LAKE
Practice Address - State:MN
Practice Address - Zip Code:56159
Practice Address - Country:US
Practice Address - Phone:218-233-5658
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN01713416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN48599MOOtherBLUE CROSS BLUE SHIELD