Provider Demographics
NPI:1588004279
Name:CRYSTAL NEW HOPE MEDICAL CLINIC
Entity type:Organization
Organization Name:CRYSTAL NEW HOPE MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:MARGIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:EVENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-356-9141
Mailing Address - Street 1:2904 JOHNSON ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-2234
Mailing Address - Country:US
Mailing Address - Phone:612-782-0900
Mailing Address - Fax:612-788-4930
Practice Address - Street 1:3501 DOUGLAS DR N
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55422-2480
Practice Address - Country:US
Practice Address - Phone:763-535-9601
Practice Address - Fax:763-535-5601
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CRYSTAL NEW HOPE MEDICAL CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-06-27
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty