Provider Demographics
NPI:1326200411
Name:MILLE LACS HEALTH SYSTEM
Entity Type:Organization
Organization Name:MILLE LACS HEALTH SYSTEM
Other - Org Name:MILLE LACS FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:UNZEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-532-2581
Mailing Address - Street 1:200 ELM ST N
Mailing Address - Street 2:PO BOX A
Mailing Address - City:ONAMIA
Mailing Address - State:MN
Mailing Address - Zip Code:56359-7901
Mailing Address - Country:US
Mailing Address - Phone:320-532-3154
Mailing Address - Fax:320-532-3111
Practice Address - Street 1:26362 370TH AVE
Practice Address - Street 2:
Practice Address - City:HILLMAN
Practice Address - State:MN
Practice Address - Zip Code:56338-2349
Practice Address - Country:US
Practice Address - Phone:320-277-3682
Practice Address - Fax:320-277-3372
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MILLE LACS HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-30
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN115808OtherUCARE MINNESOTA
MN33523MIOtherBLUE CROSS BLUE SHIELD MINNESOTA
MN630994100Medicaid
MN33523MIOtherBLUE CROSS BLUE SHIELD MINNESOTA
MN243434Medicare Oscar/Certification