Provider Demographics
NPI:1871962282
Name:THE DULUTH CLINIC, LTD.
Entity type:Organization
Organization Name:THE DULUTH CLINIC, LTD.
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:204 BELKNAP ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-2905
Mailing Address - Country:US
Mailing Address - Phone:715-817-7145
Mailing Address - Fax:715-817-7144
Practice Address - Street 1:204 BELKNAP ST STE 200
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-2905
Practice Address - Country:US
Practice Address - Phone:715-817-7145
Practice Address - Fax:715-817-7144
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ESSENTIA HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-16
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9348-423336C0003X, 3336S0011X
NDPHAR13373336C0003X
MN2650223336C0003X
IA47883336C0003X
SD400-16733336C0003X
3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1871962282Medicaid
WI100051572Medicaid
0440980024Medicare NSC