Basic Information
Provider Information | |||||||||
NPI: | 1578726311 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MILLE LACS HEALTH SYSTEM | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MILLE LACS HOME CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 200 ELM ST N | ||||||||
Address2: |   | ||||||||
City: | ONAMIA | ||||||||
State: | MN | ||||||||
PostalCode: | 563597901 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3208884127 | ||||||||
FaxNumber: | 3205324325 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/02/2008 | ||||||||
LastUpdateDate: | 03/21/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | UNZEN | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | W | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 3205322581 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MILLE LACS HEALTH SYSTEM | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |   | 163W00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse |   | 164W00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Licensed Practical Nurse |   | 225100000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 225X00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 374U00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Related Providers | Home Health Aide |   | 376J00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Related Providers | Homemaker |   | 251E00000X | 339184 | MN | Y |   | Agencies | Home Health |   |
ID Information
ID | Type | State | Issuer | Description | 123281 | 01 | MN | UCARE MINNESOTA | OTHER | 1787ACO | 01 | MN | BLUE CROSS BLUE SHIELD MINNESOTA | OTHER | 190247400 | 05 | MN |   | MEDICAID | 5900066 | 01 | MN | MEDICA | OTHER |