Provider Demographics
NPI:1295804482
Name:MOOSE LAKE COMMUNITY HOSPITAL DISTRICT
Entity type:Organization
Organization Name:MOOSE LAKE COMMUNITY HOSPITAL DISTRICT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:DELFS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-485-5858
Mailing Address - Street 1:4572 COUNTY ROAD 61
Mailing Address - Street 2:
Mailing Address - City:MOOSE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55767-9401
Mailing Address - Country:US
Mailing Address - Phone:218-485-4481
Mailing Address - Fax:218-485-5845
Practice Address - Street 1:30 ARROWHEAD LANE
Practice Address - Street 2:
Practice Address - City:MOOSE LAKE
Practice Address - State:MN
Practice Address - Zip Code:55767
Practice Address - Country:US
Practice Address - Phone:218-485-5506
Practice Address - Fax:218-485-5908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN374783251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN315245600Medicaid
MN1757AMEOtherBLUE CROSS BLUE SHIELD
MN5900060OtherMEDICA CHOICE
MN315245600Medicaid