Provider Demographics
NPI:1699708297
Name:LAKE SUPERIOR COMMUNITY HEALTH CENTER
Entity type:Organization
Organization Name:LAKE SUPERIOR COMMUNITY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-395-1955
Mailing Address - Street 1:2222 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-3709
Mailing Address - Country:US
Mailing Address - Phone:715-392-1955
Mailing Address - Fax:715-392-1935
Practice Address - Street 1:4325 GRAND AVE
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55807-2730
Practice Address - Country:US
Practice Address - Phone:218-722-1497
Practice Address - Fax:218-722-6239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN975553500Medicaid
WI32956900Medicaid
MNNA959OtherPREFERREDONE
WI32956900Medicaid
MN5100252OtherMEDICA # FOR MN SERVICES
MN654448700Medicaid
WI32957500Medicaid
MN69170DUOtherBCBS-MN# FOR MN SERVICES
MN975553500Medicaid
MN5100250OtherMEDICA# FOR WI SERVICES