Provider Demographics
NPI:1073053997
Name:EXCELLENCE COMMUNITY CLINIC CENTER
Entity Type:Organization
Organization Name:EXCELLENCE COMMUNITY CLINIC CENTER
Other - Org Name:NONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ABDIQADIR
Authorized Official - Middle Name:SALAD
Authorized Official - Last Name:HASSAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-606-8284
Mailing Address - Street 1:105 BLAKE RD N APT 206
Mailing Address - Street 2:HOPKINS
Mailing Address - City:HOPKINS
Mailing Address - State:MN
Mailing Address - Zip Code:55343-8266
Mailing Address - Country:US
Mailing Address - Phone:562-606-8284
Mailing Address - Fax:
Practice Address - Street 1:105 BLAKE RD N APT 206
Practice Address - Street 2:HOPKINS
Practice Address - City:HOPKINS
Practice Address - State:MN
Practice Address - Zip Code:55343-8266
Practice Address - Country:US
Practice Address - Phone:562-606-8284
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EXCELLENCE COMMUNITY CLINIC CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-24
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization