Provider Demographics
NPI:1700219383
Name:CENTRACARE HEALTH-PAYNESVILLE LLC
Entity Type:Organization
Organization Name:CENTRACARE HEALTH-PAYNESVILLE LLC
Other - Org Name:CENTRACARE HEALTH PAYNESVILLE - EDEN VALLEY 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 1:200 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:PAYNESVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56362-1445
Mailing Address - Country:US
Mailing Address - Phone:320-243-3767
Mailing Address - Fax:320-243-7955
Practice Address - Street 1:405 MEEKER AVE E
Practice Address - Street 2:
Practice Address - City:EDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55329-1629
Practice Address - Country:US
Practice Address - Phone:320-453-2260
Practice Address - Fax:320-453-2270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-19
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center