Healthcare Provider Details

I. General information

NPI: 1972552156
Provider Name (Legal Business Name): DULUTH KIDNEY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 11/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 E SUPERIOR ST SUITE 106
DULUTH MN
55802
US

IV. Provider business mailing address

925 E SUPERIOR ST SUITE 106
DULUTH MN
55802
US

V. Phone/Fax

Practice location:
  • Phone: 218-249-6230
  • Fax: 218-249-6231
Mailing address:
  • Phone: 218-249-6230
  • Fax: 218-249-6231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DR. SANDY POPHAM
Title or Position: OWNER MD
Credential: MD
Phone: 218-249-6230