Provider Demographics
NPI:1104902352
Name:MOOSE LAKE COMMUNITY HOSPITAL DISTRICT
Entity type:Organization
Organization Name:MOOSE LAKE COMMUNITY HOSPITAL DISTRICT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-485-5858
Mailing Address - Street 1:710 S KENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MOOSE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55767-9405
Mailing Address - Country:US
Mailing Address - Phone:218-485-4481
Mailing Address - Fax:218-485-5845
Practice Address - Street 1:710 S KENWOOD AVE
Practice Address - Street 2:
Practice Address - City:MOOSE LAKE
Practice Address - State:MN
Practice Address - Zip Code:55767-9405
Practice Address - Country:US
Practice Address - Phone:218-485-4481
Practice Address - Fax:218-485-5845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN330829282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN315245600Medicaid
MN24Z350Medicare Oscar/Certification