Provider Demographics
NPI:1245225150
Name:LAKEVIEW MEMORIAL HOSPITAL ASSOCIATION, INC.
Entity Type:Organization
Organization Name:LAKEVIEW MEMORIAL HOSPITAL ASSOCIATION, INC.
Other - Org Name:LAKEVIEW HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:GERARDETTE
Authorized Official - Middle Name:A
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:651-275-5700
Mailing Address - Street 1:5610 NORWICH PKWY
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6481
Mailing Address - Country:US
Mailing Address - Phone:651-430-3320
Mailing Address - Fax:651-275-5775
Practice Address - Street 1:5610 NORWICH PKWY
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6481
Practice Address - Country:US
Practice Address - Phone:651-430-3320
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-16
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43187200Medicaid
WI43187200Medicaid