Provider Demographics
NPI:1407227945
Name:MINUTECLINIC DIAGNOSTIC OF MINNESOTA, P.A.
Entity Type:Organization
Organization Name:MINUTECLINIC DIAGNOSTIC OF MINNESOTA, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:PINCINCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-770-3813
Mailing Address - Street 1:1 CVS DR
Mailing Address - Street 2:MC-2995
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-6146
Mailing Address - Country:US
Mailing Address - Phone:401-770-3813
Mailing Address - Fax:
Practice Address - Street 1:4241 JOHNNY CAKE RIDGE RD
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-2235
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-09
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH100308254Medicare PIN