Healthcare Provider Details

I. General information

NPI: 1568832277
Provider Name (Legal Business Name): LAKE SUPERIOR COMMUNITY HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2015
Last Update Date: 08/26/2020
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4325 GRAND AVE
DULUTH MN
55807-2730
US

IV. Provider business mailing address

3600 TOWER AVE
SUPERIOR WI
54880-5589
US

V. Phone/Fax

Practice location:
  • Phone: 218-722-1497
  • Fax: 218-727-8346
Mailing address:
  • Phone: 715-392-1955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberR 228856-1
License Number StateMN

VIII. Authorized Official

Name: KATRINA JAWORSKI
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 715-392-1955