Basic Information
Provider Information | |||||||||
NPI: | 1326180100 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LITTLEFORK MUNICIPAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PINEVIEW RECOVERY CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 912 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | LITTLEFORK | ||||||||
State: | MN | ||||||||
PostalCode: | 566539357 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2182786634 | ||||||||
FaxNumber: | 2182786637 | ||||||||
Practice Location | |||||||||
Address1: | 912 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | LITTLEFORK | ||||||||
State: | MN | ||||||||
PostalCode: | 566539357 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2182786634 | ||||||||
FaxNumber: | 2182786637 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/12/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LEHMAN | ||||||||
AuthorizedOfficialFirstName: | LILA | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | BOARD OF DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 2182784245 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 810925-1CDT | MN | Y |   | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |   |
ID Information
ID | Type | State | Issuer | Description | 5021348 | 01 | MN | MEDICA | OTHER | 6K50PI | 01 | MN | BLUE CROSS MINNESOTA | OTHER |