Provider Demographics
NPI:1023236767
Name:LAKEVIEW RESIDENCE
Entity type:Organization
Organization Name:LAKEVIEW RESIDENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-741-8996
Mailing Address - Street 1:PO BOX 1267
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA
Mailing Address - State:MN
Mailing Address - Zip Code:55792-1267
Mailing Address - Country:US
Mailing Address - Phone:218-741-8996
Mailing Address - Fax:
Practice Address - Street 1:201 N 6TH AVE
Practice Address - Street 2:
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792-2437
Practice Address - Country:US
Practice Address - Phone:218-741-8996
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility