1003478892 NPI number — THE DULUTH CLINIC LTD

Table of content: (NPI 1003478892)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003478892 NPI number — THE DULUTH CLINIC LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE DULUTH CLINIC LTD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ESSENTIA HEALTH WELLNESS CLINIC HERMANTOWN
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003478892
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/28/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4289 UGSTAD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HERMANTOWN
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55811-3615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-786-3100
Provider Business Mailing Address Fax Number:
218-576-0779

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4289 UGSTAD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HERMANTOWN
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55811-3615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-786-3100
Provider Business Practice Location Address Fax Number:
218-576-0779
Provider Enumeration Date:
07/02/2019

Additional Information

Authorized Official

Authorized Official Last Name:
BOREN
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
VP FINANCE
Authorized Official Telephone Number:
218-786-1009

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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