Provider Demographics
NPI:1881038875
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 MANAGER
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 1:901 STANLEY AVE
Mailing Address - Street 2:
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720-3186
Mailing Address - Country:US
Mailing Address - Phone:218-879-2211
Mailing Address - Fax:218-879-2233
Practice Address - Street 1:901 STANLEY AVE
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-3186
Practice Address - Country:US
Practice Address - Phone:218-879-2211
Practice Address - Fax:218-879-2233
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKE SUPERIOR MEDICAL EQUIPMENT, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-04-22
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN275S9LAOtherBLUE CROSS BLUE SHIELD
WI41725700Medicaid
MN125158900Medicaid
MN169334OtherUCARE
MN8200355OtherMEDICA/SELECT CARE
MN125158900Medicaid