Provider Demographics
NPI:1285695783
Name:LAKES REGION ARTIFICIAL LIMB AND BRACE COMPANY INC
Entity type:Organization
Organization Name:LAKES REGION ARTIFICIAL LIMB AND BRACE COMPANY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:MARVIN
Authorized Official - Last Name:HEIDE
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:218-486-1963
Mailing Address - Street 1:710 VALLEY ST
Mailing Address - Street 2:
Mailing Address - City:HAWLEY
Mailing Address - State:MN
Mailing Address - Zip Code:56549
Mailing Address - Country:US
Mailing Address - Phone:218-486-1963
Mailing Address - Fax:
Practice Address - Street 1:710 VALLEY ST
Practice Address - Street 2:
Practice Address - City:HAWLEY
Practice Address - State:MN
Practice Address - Zip Code:56549
Practice Address - Country:US
Practice Address - Phone:218-486-1963
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-01
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN110L7REOtherBLUE CROSS BLUE SHIELD MN
SD9150650Medicaid
ND54461Medicaid
8200663OtherMEDICA
SD9216690OtherDAKOTA CARE
164106OtherUCARE
23145OtherBLUE CROSS ND
8200664OtherMEDICA
MN109L7REOtherBLUE CROSS BLUE SHIELD MN
ND54461Medicaid