Provider Demographics
NPI:1639684384
Name:LAKE SUPERIOR COMMUNITY HEALTH CENTER
Entity Type:Organization
Organization Name:LAKE SUPERIOR COMMUNITY HEALTH CENTER
Other - Org Name:LAKE SUPERIOR COMMUNITY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-722-1497
Mailing Address - Street 1:1500 N 34TH ST
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-4477
Mailing Address - Country:US
Mailing Address - Phone:715-395-5380
Mailing Address - Fax:715-394-2682
Practice Address - Street 1:1500 N 34TH ST STE 200
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-4477
Practice Address - Country:US
Practice Address - Phone:715-395-5380
Practice Address - Fax:715-394-2682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-04
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)