Provider Demographics
NPI:1659509180
Name:CRESCENTERRA HEALTH CENTER, PA
Entity Type:Organization
Organization Name:CRESCENTERRA HEALTH CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:RUTHERFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-917-3990
Mailing Address - Street 1:245 PRIOR AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-5163
Mailing Address - Country:US
Mailing Address - Phone:651-917-3990
Mailing Address - Fax:651-917-3922
Practice Address - Street 1:245 PRIOR AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-5163
Practice Address - Country:US
Practice Address - Phone:651-917-3990
Practice Address - Fax:651-917-3922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-23
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1853261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center