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

4325 Grand Ave
Duluth, MN 55807-2730

Phone

(218) 722-1497

Fax

(218) 722-6239

NPI assigned

Jul 8, 2006

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) 395-1955

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in MN2 enrollments

Enrollment records 2

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1699708297. Details of each certification follow.

• CCN 241814 Federally qualified health center · Active · Details

Federally qualified health center certification: CCN 241814

Legal name

LAKE SUPERIOR COMMUNITY HEALTH CENTER

Certification status

Active

Provider type (POS)

Federally qualified health center

Participating since

May 7, 1992

Last certification

May 7, 1992

Ownership / control type

For profit – corporation

Organization structure

CorporationNon-profit

Incorporated

Feb 28, 1972 in MN

Enrollment address

4325 Grand Ave
Duluth, MN 55807-2730

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)
  • Carlton, MN
  • NPI 1760013700

  6608810031

  Same PAC ID
• Lake Superior Community Health Center

  • Federally Qualified Health Center (FQHC)
  • Superior, WI
  • NPI 1063789022

  6608810031

  Same PAC ID

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 11

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.

• Greg A McGillivray, DC

  • Chiropractor
  • Duluth, MN
  • NPI 1699771337
  Medicare reassignment Care Compare group NPD
• Kara Ward McGillivray, DC

  • Chiropractor
  • Duluth, MN
  • NPI 1255337937
  Medicare reassignment Care Compare group NPD
• Zoe Kunze, PA-C

  • Physician Assistant
  • Superior, WI
  • NPI 1780383182

  MN

  Medicare reassignment Care Compare group
• Brittany Morgan Hamm, APRN, CNP

  • Psychiatric/Mental Health Nurse Practitioner
  • Duluth, MN
  • NPI 1417598079
  Medicare reassignment NPD
• Kraig Robert Peterson, LGSW

  • Clinical Social Worker
  • Duluth, MN
  • NPI 1093293326
  Medicare reassignment NPD
• Emily J Anderson, MD

  • Family Medicine Physician
  • Superior, WI
  • NPI 1770551335

  MN

  Medicare reassignment NPD
• Jason C. Bramstedt, DC

  • Chiropractor
  • Superior, WI
  • NPI 1487647723

  MN

  Medicare reassignment NPD
• Jacob R Oestreich, MD

  • Family Medicine Physician
  • Duluth, MN
  • NPI 1700854262
  Medicare reassignment
• Aaron D Pust, MSW, LICSW

  • Clinical Social Worker
  • Superior, WI
  • NPI 1629366968

  MN

  Medicare reassignment
• Shayla Jo Tschakert, PA

  • Physician Assistant
  • Omaha, NE
  • NPI 1902526122

  MN

  Medicare reassignment
• Adam M Wennersten, PA-C

  • Physician Assistant
  • Superior, WI
  • NPI 1568619682

  MN

  Medicare reassignment

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

{
    "created_epoch": "1152316800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1707782400000",
    "number": "1699708297",
    "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": "4325 GRAND AVE",
            "city": "DULUTH",
            "state": "MN",
            "postal_code": "558072730",
            "telephone_number": "218-722-1497",
            "fax_number": "218-722-6239"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKE SUPERIOR COMMUNITY HEALTH CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-08",
        "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": "715-395-1955"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• 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
• Lake Superior Internal Medicine
• Lake Superior Medical Equipment Inc

• 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.