Provider Demographics
NPI:1255853115
Name:CENTRACARE CLINIC
Entity Type:Organization
Organization Name:CENTRACARE CLINIC
Other - Org Name:CENTRACARE - CLEARWATER CLINIC
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:56303-2735
Mailing Address - Country:US
Mailing Address - Phone:320-252-5131
Mailing Address - Fax:320-240-2118
Practice Address - Street 1:615 NELSON DRIVE
Practice Address - Street 2:PO BOX 217
Practice Address - City:CLEARWATER
Practice Address - State:MN
Practice Address - Zip Code:55320
Practice Address - Country:US
Practice Address - Phone:320-558-2293
Practice Address - Fax:320-685-4020
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRACARE CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-07-12
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care