Provider Demographics
NPI:1154437564
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 1:3500 TOWER AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-5335
Mailing Address - Country:US
Mailing Address - Phone:715-817-7880
Mailing Address - Fax:715-395-3178
Practice Address - Street 1:3500 TOWER AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-5335
Practice Address - Country:US
Practice Address - Phone:715-817-7880
Practice Address - Fax:715-395-3178
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ESSENTIA HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-21
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI78373336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2777758400Medicaid
MN51-18662OtherNCPDP
WI33072400Medicaid
MN573OtherTHE DULUTH CLINIC, LTD CHAIN CODE
MN51-18662OtherNCPDP