Provider Demographics
NPI:1558652362
Name:MANKATO CLINIC, LTD
Entity Type:Organization
Organization Name:MANKATO CLINIC, LTD
Other - Org Name:LAKE CRYSTAL FAMILY PRACTICE
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:FARROW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-389-8501
Mailing Address - Street 1:6501 CITY WEST PKWY
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-3248
Mailing Address - Country:US
Mailing Address - Phone:952-653-2525
Mailing Address - Fax:
Practice Address - Street 1:221 S MURPHY ST
Practice Address - Street 2:
Practice Address - City:LAKE CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:56055-2128
Practice Address - Country:US
Practice Address - Phone:507-726-2136
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MANKATO CLINIC, LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-27
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site