Organization
LAKE SUPERIOR COMMUNITY HEALTH CENTER
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JESSIE PETERSON (COO)
(218) 722-1497
Entity
Organization
Contact information
Practice address
3600 TOWER AVENUE, SUPERIOR, WI 54880-5337
(715) 392-1955
(715) 392-1935
Mailing address
1500 N 34TH ST STE 200, SUPERIOR, WI 54880-4477
(715) 395-5380
(715) 394-2682
Taxonomy
Speciality
Code
Description
License number
State
261QF0400X
Federally Qualified Health Center (FQHC)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
32957500
—
WI
05
—
654448700
—
MN
Enumeration date
04/23/2007
Last updated
02/08/2021
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