Provider Demographics
NPI:1225004625
Name:MANKATO CLINIC ENDOSCOPY CENTER LLC
Entity Type:Organization
Organization Name:MANKATO CLINIC ENDOSCOPY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:FARROW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-389-8501
Mailing Address - Street 1:1230 E MAIN ST
Mailing Address - Street 2:PO BOX 8674
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-5066
Mailing Address - Country:US
Mailing Address - Phone:800-657-6944
Mailing Address - Fax:
Practice Address - Street 1:1230 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-5066
Practice Address - Country:US
Practice Address - Phone:800-657-6944
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-24
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1043482OtherPREFERRED ONE
MN105111OtherHEALTH PARTNERS
MN443100600Medicaid
MN6800057OtherMEDICA
MN180538OtherUCARE MINNESOTA
FM6J32MAOtherBLUE CROSS MN
MNP00225672OtherRAILROAD MEDICARE
MNP00225672OtherRAILROAD MEDICARE