Provider Demographics
NPI:1437244431
Name:PINE CITY AREA CLINIC
Entity Type:Organization
Organization Name:PINE CITY AREA CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICK
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCMAHON
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:320-629-6721
Mailing Address - Street 1:510 2ND ST SE
Mailing Address - Street 2:
Mailing Address - City:PINE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55063-1706
Mailing Address - Country:US
Mailing Address - Phone:320-629-6721
Mailing Address - Fax:320-629-1097
Practice Address - Street 1:510 2ND ST SE
Practice Address - Street 2:
Practice Address - City:PINE CITY
Practice Address - State:MN
Practice Address - Zip Code:55063-1706
Practice Address - Country:US
Practice Address - Phone:320-629-6721
Practice Address - Fax:320-629-1097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN52757PIOtherBC/BS
MN=========OtherMEDICA
MN=========OtherMEDICA
MN243824Medicare PIN
MN52757PIOtherBC/BS