Provider Demographics
NPI:1275102048
Name:ESSENTIA HEALTH MOOSE LAKE
Entity Type:Organization
Organization Name:ESSENTIA HEALTH MOOSE LAKE
Other - Org Name:ESSENTIA HEALTH MOOSE LAKE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BEARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-786-5652
Mailing Address - Street 1:4572 COUNTY ROAD 61
Mailing Address - Street 2:
Mailing Address - City:MOOSE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55767-9401
Mailing Address - Country:US
Mailing Address - Phone:218-485-2105
Mailing Address - Fax:218-485-2170
Practice Address - Street 1:4572 COUNTY ROAD 61
Practice Address - Street 2:
Practice Address - City:MOOSE LAKE
Practice Address - State:MN
Practice Address - Zip Code:55767-9401
Practice Address - Country:US
Practice Address - Phone:218-485-2105
Practice Address - Fax:218-485-2106
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ESSENTIA HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-06-24
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC0050XAmbulatory Health Care FacilitiesClinic/CenterCritical Access Hospital