Provider Demographics
NPI:1003423252
Name:GOOD CLINIC MN PLLC
Entity Type:Organization
Organization Name:GOOD CLINIC MN PLLC
Other - Org Name:THE GOOD CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF NURSE PRACTITIONER OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:763-639-5327
Mailing Address - Street 1:1660 HIGHWAY 100 S STE 432
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1533
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4712 EXCELSIOR BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-3008
Practice Address - Country:US
Practice Address - Phone:844-383-8689
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-30
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care