Provider Demographics
NPI:1689667834
Name:LAKE REGION LUTHERAN HOME, INC.
Entity Type:Organization
Organization Name:LAKE REGION LUTHERAN HOME, INC.
Other - Org Name:HEARTLAND CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:701-662-4905
Mailing Address - Street 1:620 14TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:DEVILS LAKE
Mailing Address - State:ND
Mailing Address - Zip Code:58301-2808
Mailing Address - Country:US
Mailing Address - Phone:701-662-4905
Mailing Address - Fax:701-662-9170
Practice Address - Street 1:620 14TH AVE NE
Practice Address - Street 2:
Practice Address - City:DEVILS LAKE
Practice Address - State:ND
Practice Address - Zip Code:58301-2808
Practice Address - Country:US
Practice Address - Phone:701-662-4905
Practice Address - Fax:701-662-9170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-23
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1013A313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDD30010Medicaid
NDD30010Medicaid