Provider Demographics
NPI:1417950874
Name:INTERIM HEALTHCARE OF LAKE SUPERIOR, INC.
Entity Type:Organization
Organization Name:INTERIM HEALTHCARE OF LAKE SUPERIOR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:KARI
Authorized Official - Middle Name:JO
Authorized Official - Last Name:JARVI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-722-0053
Mailing Address - Street 1:332 W SUPERIOR ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802
Mailing Address - Country:US
Mailing Address - Phone:218-722-0053
Mailing Address - Fax:218-722-0318
Practice Address - Street 1:332 W SUPERIOR ST
Practice Address - Street 2:SUITE 204
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802
Practice Address - Country:US
Practice Address - Phone:218-722-0053
Practice Address - Fax:218-722-0318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN327241251E00000X
MN251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN109638OtherUCARE
WI41529800Medicaid
MN96435590Medicaid
MN8569INOtherBLUE CROSS BLUE SHIELD
MN964355900Medicaid
MN59-00052OtherMEDICA
MN8569INOtherBLUE CROSS BLUE SHIELD
MN247281Medicare Oscar/Certification