Provider Demographics
NPI:1811513674
Name:LAKE COUNTRY HOME CARE LLC
Entity type:Organization
Organization Name:LAKE COUNTRY HOME CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICAELA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOEHLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-385-3422
Mailing Address - Street 1:95 MILLER ST STE E
Mailing Address - Street 2:
Mailing Address - City:NEW YORK MILLS
Mailing Address - State:MN
Mailing Address - Zip Code:56567-4332
Mailing Address - Country:US
Mailing Address - Phone:218-385-3422
Mailing Address - Fax:218-385-3506
Practice Address - Street 1:95 MILLER ST STE E
Practice Address - Street 2:
Practice Address - City:NEW YORK MILLS
Practice Address - State:MN
Practice Address - Zip Code:56567-4332
Practice Address - Country:US
Practice Address - Phone:218-385-3422
Practice Address - Fax:218-385-3506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-17
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care