Provider Demographics
NPI:1477979326
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 1:2202 E 2ND ST.
Mailing Address - Street 2:SUITE 477
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-5395
Mailing Address - Country:US
Mailing Address - Phone:715-817-7999
Mailing Address - Fax:715-392-0215
Practice Address - Street 1:2202 E 2ND ST.
Practice Address - Street 2:SUITE 477
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-5395
Practice Address - Country:US
Practice Address - Phone:715-817-7999
Practice Address - Fax:715-392-0215
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ESSENTIA HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-03-14
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9247-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1477979326OtherNPI
WI100037008Medicaid
MN1477979326Medicaid