Provider Demographics
NPI:1427271089
Name:MILLE LACS ISANTI & SHERBURNE COS
Entity type:Organization
Organization Name:MILLE LACS ISANTI & SHERBURNE COS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LSN
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:K
Authorized Official - Last Name:WYGANOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-419-0211
Mailing Address - Street 1:140 BUCHANAN ST N
Mailing Address - Street 2:STE. 150
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:55008-1638
Mailing Address - Country:US
Mailing Address - Phone:763-689-3600
Mailing Address - Fax:763-689-3601
Practice Address - Street 1:706 1ST ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:MN
Practice Address - Zip Code:55371-1502
Practice Address - Country:US
Practice Address - Phone:763-389-2422
Practice Address - Fax:763-389-9142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP0905X
MN8922892251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
No261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN440643500Medicaid