- Enrollment id
- O20090819000740
- Enrollment state
- MN
- Provider type code
- 00-08
- Provider type text
- PART A PROVIDER - HOSPICE
- Npi
- 1124282272
- Multiple npi flag
- N
- Ccn
- 241588
- Associate id
- 4789577834
- Organization name
- MILLE LACS HEALTH SYSTEM
- Incorporation date
- 1990-06-20
- Incorporation state
- MN
- Organization type structure
- CORPORATION
- Proprietary nonprofit
- N
- Address line 1
- 200 ELM ST N
- City
- ONAMIA
- State
- MN
- Zip code
- 563597901