Provider Demographics
NPI:1205129756
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:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-727-0600
Mailing Address - Street 1:211 W HWY 61
Mailing Address - Street 2:PO BOX 1500
Mailing Address - City:GRAND MARAIS
Mailing Address - State:MN
Mailing Address - Zip Code:55604-1500
Mailing Address - Country:US
Mailing Address - Phone:218-387-1584
Mailing Address - Fax:218-387-1574
Practice Address - Street 1:211 W HWY 61
Practice Address - Street 2:
Practice Address - City:GRAND MARAIS
Practice Address - State:MN
Practice Address - Zip Code:55604-1500
Practice Address - Country:US
Practice Address - Phone:218-387-1584
Practice Address - Fax:218-387-1574
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKE SUPERIOR MEDICAL EQUIPMENT INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN361203332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN125158900Medicaid
WI41725700Medicaid
MN125158900Medicaid