1871962282 NPI number — THE DULUTH CLINIC, LTD.

Table of content: (NPI 1871962282)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871962282 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 SPECIALTY PHARMACY
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:
1871962282
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
204 BELKNAP ST STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUPERIOR
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54880-2905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-817-7145
Provider Business Mailing Address Fax Number:
715-817-7144

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
204 BELKNAP ST STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUPERIOR
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54880-2905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-817-7145
Provider Business Practice Location Address Fax Number:
715-817-7144
Provider Enumeration Date:
09/16/2015

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  9348-42 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PHAR1337 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 265022 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 4788 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 400-1673 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: 9348-42 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1871962282 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100051572 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com