Provider Demographics
NPI:1457387441
Name:THE DULUTH CLINIC, LTD
Entity Type:Organization
Organization Name:THE DULUTH CLINIC, LTD
Other - Org Name:ESSENTIA HEALTH VIRGINIA CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-786-1009
Mailing Address - Street 1:1101 9TH ST N
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA
Mailing Address - State:MN
Mailing Address - Zip Code:55792-2329
Mailing Address - Country:US
Mailing Address - Phone:218-741-0150
Mailing Address - Fax:218-749-7844
Practice Address - Street 1:1101 9TH ST N
Practice Address - Street 2:
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792-2329
Practice Address - Country:US
Practice Address - Phone:218-741-0150
Practice Address - Fax:218-749-7844
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ESSENTIA HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-23
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1457387441Medicaid
0440980009Medicare NSC
MN1457387441Medicaid
MNC02516Medicare PIN