1831204940 NPI number — THE DULUTH CLINIC, LTD

Table of content: (NPI 1831204940)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831204940 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 LAKESIDE 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:
1831204940
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:
4621 E SUPERIOR ST
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55804-2338
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-786-3784
Provider Business Mailing Address Fax Number:
218-525-7338

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4621 E SUPERIOR ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55804-2338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-786-3784
Provider Business Practice Location Address Fax Number:
218-525-7338
Provider Enumeration Date:
08/20/2006

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:  2612425 , 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: 106358800 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 573 . This is a "THE DULUTH CLINIC, LTD CHAIN CODE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 24-04642 . This is a "NCPDP" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 33163300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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