Provider Demographics
NPI:1912998089
Name:LAKEWOOD HEALTH SYSTEM
Entity Type:Organization
Organization Name:LAKEWOOD HEALTH SYSTEM
Other - Org Name:LAKEWOOD CLINIC MOTLEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLHOWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-894-8600
Mailing Address - Street 1:49725 COUNTY 83
Mailing Address - Street 2:
Mailing Address - City:STAPLES
Mailing Address - State:MN
Mailing Address - Zip Code:56479-5280
Mailing Address - Country:US
Mailing Address - Phone:218-894-1515
Mailing Address - Fax:218-898-7596
Practice Address - Street 1:1233 HIGHWAY 10 S
Practice Address - Street 2:
Practice Address - City:MOTLEY
Practice Address - State:MN
Practice Address - Zip Code:56466-8209
Practice Address - Country:US
Practice Address - Phone:218-352-6922
Practice Address - Fax:218-898-7594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
C04082Medicare PIN
243431Medicare Oscar/Certification
MN243431Medicare ID - Type Unspecified
MN1251620006OtherADMINASTAR FEDERAL (NATIONAL GOVERNMENT SERVICES)