Provider Demographics
NPI:1477599918
Name:APPLE VALLEY MEDICAL CLINIC, LTD.
Entity Type:Organization
Organization Name:APPLE VALLEY MEDICAL CLINIC, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SYSTEMS MANAGER/SECURITY OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:WASSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-997-9313
Mailing Address - Street 1:14655 GALAXIE AVE
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-8575
Mailing Address - Country:US
Mailing Address - Phone:952-432-6161
Mailing Address - Fax:952-432-7019
Practice Address - Street 1:14655 GALAXIE AVE
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124
Practice Address - Country:US
Practice Address - Phone:952-432-6161
Practice Address - Fax:952-432-7019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN723207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN989883200Medicaid
MNCE7163OtherMEDICARE RAILROAD
MN22345APOtherBLUE CROSS BLUE SHIELD
MN6792510001OtherMEDICARE
MN858098OtherPREFERRED ONE
MN594010900Medicaid
C00152OtherPTAN
MN55108OtherHEALTHPARTNERS UC
MN587OtherHEALTHPARTNERS
C00152OtherPTAN
MN6792510001Medicare NSC