Provider Demographics
NPI:1467094102
Name:LAKE COUNTRY LIVING SERVICES LLC
Entity Type:Organization
Organization Name:LAKE COUNTRY LIVING SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CEO
Authorized Official - Prefix:
Authorized Official - First Name:NATALIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BURDICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-242-2498
Mailing Address - Street 1:181 LITTLE ROCK RD NW
Mailing Address - Street 2:
Mailing Address - City:RICE
Mailing Address - State:MN
Mailing Address - Zip Code:56367-8685
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:181 LITTLE ROCK RD NW
Practice Address - Street 2:
Practice Address - City:RICE
Practice Address - State:MN
Practice Address - Zip Code:56367-8685
Practice Address - Country:US
Practice Address - Phone:218-242-2498
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-15
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency