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

210 3Rd St
Carlton, MN 55718-7703

Phone

(218) 336-3524

Fax

(218) 384-9002

NPI assigned

Jan 29, 2020

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 MN

Enrollment records 1

Federally qualified health center certification: CCN 241897

Legal name

LAKE SUPERIOR COMMUNITY HEALTH CENTER

Certification status

Active

Provider type (POS)

Federally qualified health center

Participating since

Jan 10, 2022

Last certification

Jan 10, 2022

Ownership / control type

For profit – corporation

Organization structure

CorporationNon-profit

Enrollment address

210 3Rd St
Carlton, MN 55718-7703

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)
  • Superior, WI
  • NPI 1063789022

  6608810031

  Same PAC ID

Tax ID family

Lake Superior Community Health Center2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

• Lake Superior Community Health Center

  • Federally Qualified Health Center (FQHC)
  • Duluth, MN
  • NPI 1568832277
  NPD tax ID

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.

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

{
    "created_epoch": "1580256000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1707782400000",
    "number": "1760013700",
    "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": "210 3RD ST",
            "city": "CARLTON",
            "state": "MN",
            "postal_code": "557187703",
            "telephone_number": "218-336-3524",
            "fax_number": "218-384-9002"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKE SUPERIOR COMMUNITY HEALTH CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-01-29",
        "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": []
}

• Inter-Faith Care Center
• Kristen Marie Jaster, APRN, CNP
• Kirsten K Komarek, RDH
• Steven Boyd Kottke, DDS
• Kimberly Kroll, OTR
• Cristy Sue Leonard-Rivers, LPCC
• Gina Mott, RN
• Linda Newlon, RPT
• Northwoods Counseling, LLC
• Wendy Ann Peterson, DMD

• Federally Qualified Health Center (FQHC) in Carlton, MN
• Providers in Carlton, 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.