Provider Demographics
NPI:1568832277
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:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:KATRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:JAWORSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-392-1955
Mailing Address - Street 1:3600 TOWER AVE
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-5589
Mailing Address - Country:US
Mailing Address - Phone:715-392-1955
Mailing Address - Fax:
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:218-727-8346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-07
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QF0400X
MNR 228856-1261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care