=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538506894
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE DULUTH CLINIC, LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2013
-----------------------------------------------------
Last Update Date | 02/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 901 9TH ST N
-----------------------------------------------------
City | VIRGINIA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55792-2325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-741-3340
-----------------------------------------------------
Fax | 218-749-9427
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 901 9TH ST N
-----------------------------------------------------
City | VIRGINIA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55792-2325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-741-3340
-----------------------------------------------------
Fax | 218-749-9427
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OF FINANCE
-----------------------------------------------------
Name | KEVIN BOREN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 218-786-1009
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number | 361396
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------