Provider Demographics
NPI:1497759864
Name:LAKE SUPERIOR MEDICAL EQUIPMENT INC
Entity Type:Organization
Organization Name:LAKE SUPERIOR MEDICAL EQUIPMENT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:WATTERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-727-0600
Mailing Address - Street 1:522 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1936
Mailing Address - Country:US
Mailing Address - Phone:218-727-0600
Mailing Address - Fax:218-727-2209
Practice Address - Street 1:522 E 4TH ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-1936
Practice Address - Country:US
Practice Address - Phone:218-727-0600
Practice Address - Fax:218-727-2209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-13
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5762874332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN125158900Medicaid
MN169334OtherUCARE
MN8200355OtherMEDICA/SELECT CARE
WI41725700Medicaid
MN275S9LAOtherBLUE CROSS BLUE SHIELD
MN275S9LAOtherBLUE CROSS BLUE SHIELD