Provider Demographics
NPI:1366545386
Name:LISBON AREA HEALTH SERVICES
Entity type:Organization
Organization Name:LISBON AREA HEALTH SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:701-683-6419
Mailing Address - Street 1:PO BOX 353
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:ND
Mailing Address - Zip Code:58054-0353
Mailing Address - Country:US
Mailing Address - Phone:701-683-3095
Mailing Address - Fax:701-683-3282
Practice Address - Street 1:920 MAIN ST
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:ND
Practice Address - Zip Code:58054-4363
Practice Address - Country:US
Practice Address - Phone:701-683-3095
Practice Address - Fax:701-683-3282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4055B251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND54117Medicaid
ND54117Medicaid