Healthcare Provider Details

I. General information

NPI: 1366211898
Provider Name (Legal Business Name): LAKE SUPERIOR HOME HEALTH CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2023
Last Update Date: 12/26/2023
Certification Date: 12/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 W DIVISION ST
ISHPEMING MI
49849-2340
US

IV. Provider business mailing address

330 W DIVISION ST
ISHPEMING MI
49849-2340
US

V. Phone/Fax

Practice location:
  • Phone: 906-630-0529
  • Fax: 877-795-1376
Mailing address:
  • Phone: 906-630-0529
  • Fax: 877-795-1376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State

VIII. Authorized Official

Name: PAUL KLUTTS
Title or Position: DOCS, CEO
Credential: DOCS, CEO
Phone: 906-630-0529