Provider Demographics
NPI:1376056481
Name:LICE LOUNGE DULUTH, LLC
Entity Type:Organization
Organization Name:LICE LOUNGE DULUTH, LLC
Other - Org Name:LICE LOUNGE DULUTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, COO
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:RHEA
Authorized Official - Last Name:MERRIMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-815-3644
Mailing Address - Street 1:2335 GASTON AVE
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR TOWNSHIP
Mailing Address - State:MN
Mailing Address - Zip Code:55110-2338
Mailing Address - Country:US
Mailing Address - Phone:651-815-3644
Mailing Address - Fax:
Practice Address - Street 1:113 N 2ND AVE W
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1911
Practice Address - Country:US
Practice Address - Phone:218-382-5423
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-10
Last Update Date:2017-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local