Provider Demographics
NPI:1558600874
Name:CENTRACARE HEALTH SYSTEM-NR LLC
Entity Type:Organization
Organization Name:CENTRACARE HEALTH SYSTEM-NR LLC
Other - Org Name:CENTRACARE - MONTICELLO SPECIALTY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VICE PRESIDENT AND CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-255-5665
Mailing Address - Street 1:1107 HART BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-8538
Mailing Address - Country:US
Mailing Address - Phone:763-271-2276
Mailing Address - Fax:763-271-1799
Practice Address - Street 1:1107 HART BLVD
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-8538
Practice Address - Country:US
Practice Address - Phone:763-271-2276
Practice Address - Fax:763-271-1799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-06
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty