Provider Demographics
NPI:1457355844
Name:LAKESHORE INN NURSING HOME INC
Entity Type:Organization
Organization Name:LAKESHORE INN NURSING HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:R. P.
Authorized Official - Middle Name:
Authorized Official - Last Name:MADEL
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:507-835-2800
Mailing Address - Street 1:108 8TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WASECA
Mailing Address - State:MN
Mailing Address - Zip Code:56093-1912
Mailing Address - Country:US
Mailing Address - Phone:507-835-2800
Mailing Address - Fax:507-833-1391
Practice Address - Street 1:108 8TH ST NW
Practice Address - Street 2:
Practice Address - City:WASECA
Practice Address - State:MN
Practice Address - Zip Code:56093-1912
Practice Address - Country:US
Practice Address - Phone:507-835-2800
Practice Address - Fax:507-833-1391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-13
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9058850314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN593043000Medicaid
MN7100427OtherMEDICA
MNNH0444OtherUCARE/SCHA
MN8656LAOtherBCBS OF MN
MNNH0444OtherUCARE/SCHA