Lake Superior Community Health Center

Primary specialty

Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X

Legal business name

LAKE SUPERIOR COMMUNITY HEALTH CENTER

Practice address

4602 Grand Ave Ste 1000
Duluth, MN 55807-2712

Phone

(218) 336-3520

Fax

(218) 624-6097

NPI assigned

Dec 30, 2019

Last updated

Feb 13, 2024By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Lee Homan

Title

Ceo

Phone

(715) 392-1955

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1013556638. Details of each certification follow.

• CCN 241892 Federally qualified health center · Active · Name & address match · Details

Federally qualified health center certification: CCN 241892

Legal name

LAKE SUPERIOR COMMUNITY HEALTH CENTER

Certification status

Active

Provider type (POS)

Federally qualified health center

Participating since

Sep 17, 2020

Last certification

Sep 17, 2020

Ownership / control type

For profit – corporation

Facility address

4602 Grand Avenue Ste 1000
Duluth, MN 55807

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1577664000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1707782400000",
    "number": "1013556638",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2222 E 5TH ST",
            "city": "SUPERIOR",
            "state": "WI",
            "postal_code": "548803709",
            "telephone_number": "715-392-1955",
            "fax_number": "715-392-1935"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4602 GRAND AVE STE 1000",
            "city": "DULUTH",
            "state": "MN",
            "postal_code": "558072712",
            "telephone_number": "218-336-3520",
            "fax_number": "218-624-6097"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKE SUPERIOR COMMUNITY HEALTH CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-12-30",
        "last_updated": "2024-02-13",
        "certification_date": "2024-02-13",
        "status": "A",
        "authorized_official_last_name": "HOMAN",
        "authorized_official_first_name": "LEE",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "715-392-1955"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Sharon Diane Lahti, SLP
• Lake Dental PLLC
• Lake Effect Psychotherapy Group LLC
• Lake Superior Area Family Services
• Lake Superior College Dental Clinic
• Lake Superior Community Health Center
• Lake Superior Community Health Center
• Lake Superior Concierge, Inc.
• Lake Superior Counseling Center
• Lake Superior Dental Associates

• Federally Qualified Health Center (FQHC) in Duluth, MN
• Providers in Duluth, MN by specialty
• Federally Qualified Health Center (FQHC) in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 13, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.