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

2222 E 5TH St
Superior, WI 54880-3709

Phone

(715) 392-1955

Fax

(715) 392-1935

NPI assigned

Nov 18, 2011

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

Enrolled in WI2 enrollments

Enrollment records 2

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1063789022. Details of each certification follow.

• CCN 521877 Federally qualified health center · Active · Details

Federally qualified health center certification: CCN 521877

Legal name

LAKE SUPERIOR COMMUNITY HEALTH CENTER

Certification status

Active

Provider type (POS)

Federally qualified health center

Participating since

Nov 16, 2021

Last certification

Nov 16, 2021

Ownership / control type

For profit – corporation

Organization structure

CorporationNon-profit

Incorporated

Feb 28, 1972 in WI

Enrollment address

2222 E 5TH St
Superior, WI 54880-3709

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

• Lake Superior Community Health Center

  • Federally Qualified Health Center (FQHC)
  • Duluth, MN
  • NPI 1699708297

  6608810031

  Same PAC ID
• Lake Superior Community Health Center

  • Federally Qualified Health Center (FQHC)
  • Carlton, MN
  • NPI 1760013700

  6608810031

  Same PAC ID

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

• Lake Superior Community Health Center

  • Federally Qualified Health Center (FQHC)
  • Superior, WI
  • NPI 1578781639

  O20110205000134

  Same enrollment

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

All disclosed owners & managing parties 16

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Aaron D Pust, MSW, LICSW

  • Clinical Social Worker
  • Superior, WI
  • NPI 1629366968
  Medicare reassignment Care Compare group NPD
• Adam M Wennersten, PA-C

  • Physician Assistant
  • Superior, WI
  • NPI 1568619682
  Medicare reassignment Care Compare group NPD
• Jacob R Oestreich, MD

  • Family Medicine Physician
  • Duluth, MN
  • NPI 1700854262

  WI

  Medicare reassignment Care Compare group NPD
• Shayla Jo Tschakert, PA

  • Physician Assistant
  • Omaha, NE
  • NPI 1902526122

  WI

  Medicare reassignment Care Compare group NPD
• Emily J Anderson, MD

  • Family Medicine Physician
  • Superior, WI
  • NPI 1770551335
  Medicare reassignment NPD
• Jason C. Bramstedt, DC

  • Chiropractor
  • Superior, WI
  • NPI 1487647723
  Medicare reassignment NPD
• Zoe Kunze, PA-C

  • Physician Assistant
  • Superior, WI
  • NPI 1780383182
  Medicare reassignment NPD
• Brittany Morgan Hamm, APRN, CNP

  • Psychiatric/Mental Health Nurse Practitioner
  • Duluth, MN
  • NPI 1417598079

  WI

  Medicare reassignment NPD
• Kraig Robert Peterson, LGSW

  • Clinical Social Worker
  • Duluth, MN
  • NPI 1093293326

  WI

  Medicare reassignment NPD

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

{
    "created_epoch": "1321574400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1707782400000",
    "number": "1063789022",
    "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": "2222 E 5TH ST",
            "city": "SUPERIOR",
            "state": "WI",
            "postal_code": "548803709",
            "telephone_number": "715-392-1955",
            "fax_number": "715-392-1935"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKE SUPERIOR COMMUNITY HEALTH CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-11-18",
        "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": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Debrah Dee Labarre, MD
• James Oscar Laberge, PHARMD
• Amy Marie Laflamme, P.A.
• Kimberly Ann Laible, C.O.T.A.
• Lake Superior Chiropractic Office, S.C.
• Lake Superior Community Health Center
• Lake Superior Community Health Center
• James Sebastian Lane
• Ryan Michael Sahand Lane, MSW, LGSW
• Lange Chiropractic Centers, S.C. (Lange-Laughlin Chiropractic Center)

• Federally Qualified Health Center (FQHC) in Superior, WI
• Providers in Superior, WI by specialty
• Federally Qualified Health Center (FQHC) in Wisconsin

• 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.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.