Provider Demographics
NPI:1013153907
Name:FOREST LAKE SKIN AND VEIN CLINIC
Entity Type:Organization
Organization Name:FOREST LAKE SKIN AND VEIN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LESA
Authorized Official - Middle Name:RENAE
Authorized Official - Last Name:STEGNER
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:651-464-7273
Mailing Address - Street 1:280 12TH ST SW
Mailing Address - Street 2:SUITE A
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-3778
Mailing Address - Country:US
Mailing Address - Phone:651-464-7273
Mailing Address - Fax:651-464-7969
Practice Address - Street 1:280 12TH ST SW
Practice Address - Street 2:SUITE A
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-3778
Practice Address - Country:US
Practice Address - Phone:651-464-7273
Practice Address - Fax:651-464-7969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-23
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNQ00953Medicare UPIN
MNH70496Medicare UPIN