MEDICARE: INTERIM HEALTHCARE OF LAKE SUPERIOR, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency	327241	MN
2	251E00000X	Home Health Agency		MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	109638	OTHER	MN	UCARE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	8569IN	OTHER	MN	BLUE CROSS BLUE SHIELD
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	59-00052	OTHER	MN	MEDICA

General Provider Information

NPI Number	:	1417950874
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERIM HEALTHCARE OF LAKE SUPERIOR, INC.

Provider Business Mailing Address
First Line	:	332 W SUPERIOR ST
Second Line	:	SUITE 204
City	:	DULUTH
State	:	MN
Zip	:	55802
Country	:	US
Telephone Number	:	218-722-0053
Fax Number	:	218-722-0318

Provider Business Practice Location Address
First Line	:	332 W SUPERIOR ST
Second Line	:	SUITE 204
City	:	DULUTH
State	:	MN
Zip	:	55802
Country	:	US
Telephone Number	:	218-722-0053
Fax Number	:	218-722-0318

Authorized Official
Title or Position	:	CONTROLLER
Name	:	KARI JO JARVI
Credential	:
Telephone Number	:	218-722-0053

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	10/08/2019

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