Provider Demographics
NPI:1851455323
Name:LAKE REGION HALFWAY HOMES, INC.
Entity Type:Organization
Organization Name:LAKE REGION HALFWAY HOMES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREATMENT DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHERRI
Authorized Official - Middle Name:E
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:LADC
Authorized Official - Phone:218-739-9084
Mailing Address - Street 1:217 N UNION AVE
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-2127
Mailing Address - Country:US
Mailing Address - Phone:218-739-9084
Mailing Address - Fax:218-739-0518
Practice Address - Street 1:217 N UNION AVE
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-2127
Practice Address - Country:US
Practice Address - Phone:218-739-9084
Practice Address - Fax:218-739-0518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN801334-2-CDT324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN726555700OtherMHCP PROVIDER NUMBER