Provider Demographics
NPI:1376698522
Name:LAKE HEALTH DISTRICT
Entity Type:Organization
Organization Name:LAKE HEALTH DISTRICT
Other - Org Name:LAKE DISTRICT HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:BODELL
Authorized Official - Last Name:TVEIT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-947-7307
Mailing Address - Street 1:700 S J ST
Mailing Address - Street 2:
Mailing Address - City:LAKEVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97630-1623
Mailing Address - Country:US
Mailing Address - Phone:541-947-2114
Mailing Address - Fax:541-947-2433
Practice Address - Street 1:700 S J ST
Practice Address - Street 2:
Practice Address - City:LAKEVIEW
Practice Address - State:OR
Practice Address - Zip Code:97630-1623
Practice Address - Country:US
Practice Address - Phone:541-947-2114
Practice Address - Fax:541-947-2433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR140896261QC0050X, 282NC0060X
OR1836773096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No261QC0050XAmbulatory Health Care FacilitiesClinic/CenterCritical Access Hospital
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR802595OtherMEDICAIDORE.HEALTHL.T.C.
OR107532OtherMEDICAID OREGON HEALTH
OR106146Medicaid
OK381545Medicare ID - Type UnspecifiedHOSPICE
OR106146Medicaid
OR107532OtherMEDICAID OREGON HEALTH
OKR0000ZGBMedicare ID - Type UnspecifiedMEDICAREN.DAKOTA PROFEE
OR381309Medicare Oscar/Certification
OR387141Medicare ID - Type UnspecifiedHOME HEALTH
OR38Z309Medicare Oscar/Certification