Provider Demographics
NPI:1407282809
Name:TARGET CLINIC MINNESOTA
Entity Type:Organization
Organization Name:TARGET CLINIC MINNESOTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING CONTACT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:TEUFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-761-6395
Mailing Address - Street 1:PO BOX 9066
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-9066
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1650 NEW BRIGHTON BLVD
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-1643
Practice Address - Country:US
Practice Address - Phone:612-781-7033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-18
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR16914-2363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty