Provider Demographics
NPI:1548420037
Name:LAKE VIEW CLINIC
Entity Type:Organization
Organization Name:LAKE VIEW CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:GARRETT
Authorized Official - Last Name:RUBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-834-7345
Mailing Address - Street 1:325 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:TWO HARBORS
Mailing Address - State:MN
Mailing Address - Zip Code:55616-1300
Mailing Address - Country:US
Mailing Address - Phone:218-834-7300
Mailing Address - Fax:218-834-7388
Practice Address - Street 1:325 11TH AVE
Practice Address - Street 2:
Practice Address - City:TWO HARBORS
Practice Address - State:MN
Practice Address - Zip Code:55616-1300
Practice Address - Country:US
Practice Address - Phone:218-834-7200
Practice Address - Fax:218-834-7220
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKE VIEW MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-10
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN331064207Q00000X, 282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty