Basic Information
| Provider Information | |||||||||
| NPI: | 1013556638 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKE SUPERIOR COMMUNITY HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2222 E 5TH ST | ||||||||
| Address2: | |||||||||
| City: | SUPERIOR | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548803709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153921955 | ||||||||
| FaxNumber: | 7153921935 | ||||||||
| Practice Location | |||||||||
| Address1: | 4602 GRAND AVE STE 1000 | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558072712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183363520 | ||||||||
| FaxNumber: | 2186246097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2019 | ||||||||
| LastUpdateDate: | 02/03/2022 | ||||||||
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| AuthorizedOfficialLastName: | PETERSON | ||||||||
| AuthorizedOfficialFirstName: | JESSIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7153921955 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.