Provider Demographics
NPI:1063881399
Name:THE DULUTH CLINIC, LTD.
Entity type:Organization
Organization Name:THE DULUTH CLINIC, LTD.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-786-1009
Mailing Address - Street 1:204 BELKNAP ST STE 300
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-2905
Mailing Address - Country:US
Mailing Address - Phone:715-817-7146
Mailing Address - Fax:715-817-7144
Practice Address - Street 1:204 BELKNAP ST STE 300
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-2905
Practice Address - Country:US
Practice Address - Phone:715-817-7146
Practice Address - Fax:715-817-7144
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ESSENTIA HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-16
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2650743336C0003X
NDPHAR13173336C0003X
IA47873336C0003X
ID46322MS3336C0003X
NMPH000044373336C0003X
WYNR-513033336C0003X
AZY0071163336C0003X
FLPH307433336C0003X
SD400-17213336C0003X
WI9349-423336M0002X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100054637Medicaid
MN1063881399Medicaid
0440980023Medicare NSC