Provider Demographics
NPI:1467593251
Name:LAKES MEDI-VAN INC.
Entity Type:Organization
Organization Name:LAKES MEDI-VAN INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:NUSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-422-0976
Mailing Address - Street 1:PO BOX 1053
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56502-1053
Mailing Address - Country:US
Mailing Address - Phone:800-422-0976
Mailing Address - Fax:877-417-4380
Practice Address - Street 1:16777 LONGVIEW DRIVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501
Practice Address - Country:US
Practice Address - Phone:800-422-0976
Practice Address - Fax:877-417-4380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN153579343900000X
MN153619343900000X
MN153636343900000X
MN153581343900000X
MN153577343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN11033LAOtherBLUE PLUS
MN8120863OtherMEDICA
MN16726OtherHEALTH PARTNERS
ND56330Medicaid
MN109465OtherUCARE
SD9030210Medicaid