Provider Demographics
NPI:1922471804
Name:LAKE REGION HEALTHCARE CORPORATION
Entity Type:Organization
Organization Name:LAKE REGION HEALTHCARE CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PHIBBS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:218-736-8687
Mailing Address - Street 1:712 S CASCADE ST
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-2913
Mailing Address - Country:US
Mailing Address - Phone:218-736-8000
Mailing Address - Fax:
Practice Address - Street 1:111 W VERNON AVE
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-2741
Practice Address - Country:US
Practice Address - Phone:218-736-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-02
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1783332B00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332H00000XSuppliersEyewear Supplier