Provider Demographics
NPI:1386759496
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 1:11134 N STATE ROAD 77 STE A
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-5325
Mailing Address - Country:US
Mailing Address - Phone:715-634-6774
Mailing Address - Fax:715-634-5517
Practice Address - Street 1:11134 N STATE ROAD 77 STE A
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-5325
Practice Address - Country:US
Practice Address - Phone:715-634-6774
Practice Address - Fax:715-634-5517
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST.. MARY'S DULUTH CLINIC HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-20
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI77723336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN573OtherTHE DULUTH CLINIC, LTD CHAIN CODE
WI33232000Medicaid
WI448819900Medicaid
MN51-24401OtherNCPDP
MN51-24401OtherNCPDP