Provider Demographics
NPI:1164766010
Name:HIAWATHA CLINIC CENTER LLC
Entity Type:Organization
Organization Name:HIAWATHA CLINIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:HUDO
Authorized Official - Middle Name:O
Authorized Official - Last Name:MIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-308-8842
Mailing Address - Street 1:2275 SNELLING AVE N APT 309
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-4285
Mailing Address - Country:US
Mailing Address - Phone:651-308-8842
Mailing Address - Fax:612-225-6758
Practice Address - Street 1:2275 SNELLING AVE N APT 309
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-4285
Practice Address - Country:US
Practice Address - Phone:651-308-8842
Practice Address - Fax:612-225-6758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit