Provider Demographics
NPI:1942247762
Name:THE DULUTH CLINIC, LTD
Entity Type:Organization
Organization Name:THE DULUTH CLINIC, LTD
Other - Org Name:VIRGINIA WEST CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EX. VP & SR. OFFICER DC OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMYLIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-786-2625
Mailing Address - Street 1:901 9TH ST N
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA
Mailing Address - State:MN
Mailing Address - Zip Code:55792-2348
Mailing Address - Country:US
Mailing Address - Phone:218-749-7953
Mailing Address - Fax:
Practice Address - Street 1:901 9TH ST N
Practice Address - Street 2:
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792-2348
Practice Address - Country:US
Practice Address - Phone:218-749-7953
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN02517Medicare ID - Type Unspecified