Basic Information
| Provider Information | |||||||||
| NPI: | 1497917587 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MILLE LACS HEALTH SYSTEM | ||||||||
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| OtherOrganizationName: | MILLE LACS FAMILY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 ELM ST N | ||||||||
| Address2: | PO BOX A | ||||||||
| City: | ONAMIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563597901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3205323154 | ||||||||
| FaxNumber: | 3205323111 | ||||||||
| Practice Location | |||||||||
| Address1: | 375 W ISLE ST | ||||||||
| Address2: | |||||||||
| City: | ISLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563422640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206763661 | ||||||||
| FaxNumber: | 3206764011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2008 | ||||||||
| LastUpdateDate: | 05/13/2013 | ||||||||
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| AuthorizedOfficialLastName: | UNZEN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3205322581 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MILLE LACS HEALTH SYSTEM | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | 163WD0400X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Diabetes Educator | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363AM0700X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 33523MI | 01 | MN | BLUE CROSS BLUE SHIELD MINNESOTA | OTHER | 566354700 | 05 | MN | MEDICAID | 115807 | 01 | MN | UCARE MINNESOTA | OTHER |