Provider Demographics
NPI:1417108531
Name:MILLE LACS HEALTH SYSTEM
Entity Type:Organization
Organization Name:MILLE LACS HEALTH SYSTEM
Other - Org Name:MILLE LACS CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:KNUTSON
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 1:150 10TH ST NW
Practice Address - Street 2:
Practice Address - City:MILACA
Practice Address - State:MN
Practice Address - Zip Code:56353-1737
Practice Address - Country:US
Practice Address - Phone:320-532-3154
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MILLE LACS HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-07
Last Update Date:2022-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2280111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC04527Medicare Oscar/Certification