Provider Demographics
NPI:1710127139
Name:CITY OF MINNESOTA LAKE
Entity Type:Organization
Organization Name:CITY OF MINNESOTA LAKE
Other - Org Name:MINNESOTA LAKE AMBULANCE SERVICE
Other - Org Type:Other Name
Authorized Official - Title/Position:CITY CLERK-TREASURER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:GRUNZKE
Authorized Official - Suffix:
Authorized Official - Credentials:CMC
Authorized Official - Phone:507-462-3277
Mailing Address - Street 1:103 MAIN ST. N
Mailing Address - Street 2:PO BOX 98
Mailing Address - City:MINNESOTA LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56068-0098
Mailing Address - Country:US
Mailing Address - Phone:507-462-3277
Mailing Address - Fax:507-462-3438
Practice Address - Street 1:10001 LAKE AVE
Practice Address - Street 2:
Practice Address - City:MINNESOTA LAKE
Practice Address - State:MN
Practice Address - Zip Code:56068-0098
Practice Address - Country:US
Practice Address - Phone:507-462-3277
Practice Address - Fax:507-462-3438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-25
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN0163341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN599000036Medicare PIN