Provider Demographics
NPI:1134665359
Name:CENTRACARE CLINIC
Entity Type:Organization
Organization Name:CENTRACARE CLINIC
Other - Org Name:CENTRACARE NEUROSCIENCES HEADACHE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP & CFO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-255-5665
Mailing Address - Street 1:1200 6TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2736
Mailing Address - Country:US
Mailing Address - Phone:320-229-4977
Mailing Address - Fax:
Practice Address - Street 1:2001 STOCKINGER DR STE 100
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1243
Practice Address - Country:US
Practice Address - Phone:320-534-3096
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-11
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty