Provider Demographics
NPI:1477869311
Name:CHILDREN'S HEALTH CARE
Entity Type:Organization
Organization Name:CHILDREN'S HEALTH CARE
Other - Org Name:NORTHEAST PEDIATRIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MASSMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-813-6113
Mailing Address - Street 1:2910 CENTRE POINTE DR
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-1182
Mailing Address - Country:US
Mailing Address - Phone:651-855-2109
Mailing Address - Fax:651-855-2310
Practice Address - Street 1:4520 CENTERVILLE RD
Practice Address - Street 2:
Practice Address - City:VADNAIS HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55127-3602
Practice Address - Country:US
Practice Address - Phone:651-426-1141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-30
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN347125261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care