1497759864 NPI number — LAKE SUPERIOR MEDICAL EQUIPMENT INC

Table of content: (NPI 1497759864)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497759864 NPI number — LAKE SUPERIOR MEDICAL EQUIPMENT INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE SUPERIOR MEDICAL EQUIPMENT INC
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:
Provider Other Organization Name Type Code:
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:
1497759864
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
522 E 4TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55805-1936
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-727-0600
Provider Business Mailing Address Fax Number:
218-727-2209

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
522 E 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55805-1936
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-727-0600
Provider Business Practice Location Address Fax Number:
218-727-2209
Provider Enumeration Date:
06/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WATTERS
Authorized Official First Name:
KATHY
Authorized Official Middle Name:
Authorized Official Title or Position:
GENERAL MGR
Authorized Official Telephone Number:
218-727-0600

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  5762874 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 125158900 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 169334 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 8200355 . This is a "MEDICA/SELECT CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 41725700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 275S9LA . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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