Basic Information
Provider Information | |||||||||
NPI: | 1831130319 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MAYO CLINIC HEALTH SYSTEM-LAKE CITY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 500 W GRANT ST | ||||||||
Address2: |   | ||||||||
City: | LAKE CITY | ||||||||
State: | MN | ||||||||
PostalCode: | 550411143 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6513453321 | ||||||||
FaxNumber: | 6513451151 | ||||||||
Practice Location | |||||||||
Address1: | 500 W GRANT ST | ||||||||
Address2: |   | ||||||||
City: | LAKE CITY | ||||||||
State: | MN | ||||||||
PostalCode: | 550411143 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6513453321 | ||||||||
FaxNumber: | 6513451151 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/08/2006 | ||||||||
LastUpdateDate: | 03/24/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MEKALA | ||||||||
AuthorizedOfficialFirstName: | PRAVEEN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 5075946449 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MAYO CLINIC HEALTH SYSTEM-LAKE CITY | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/24/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X |   | MN | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 715522100 | 05 | MN |   | MEDICAID |