Provider Demographics
NPI:1407496219
Name:HOPE MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:HOPE MEDICAL CLINIC LLC
Other - Org Name:HOPE MOBILE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:WANYAMA
Authorized Official - Suffix:
Authorized Official - Credentials:APRN,CNP
Authorized Official - Phone:763-377-2069
Mailing Address - Street 1:7325 ZANE AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-3113
Mailing Address - Country:US
Mailing Address - Phone:763-377-2069
Mailing Address - Fax:
Practice Address - Street 1:200 W LAKE ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-3023
Practice Address - Country:US
Practice Address - Phone:952-219-2773
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOPE MEDICAL CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-01-09
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty