Provider Demographics
NPI:1710048590
Name:CENTRACARE CLINIC
Entity Type:Organization
Organization Name:CENTRACARE CLINIC
Other - Org Name:CENTRACARE - BECKER CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP & CFO
Authorized Official - Prefix:
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 1:1200 6TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2736
Mailing Address - Country:US
Mailing Address - Phone:320-229-4977
Mailing Address - Fax:
Practice Address - Street 1:12800 ROLLING RIDGE
Practice Address - Street 2:CENTRACARE CLINIC BECKER
Practice Address - City:BECKER
Practice Address - State:MN
Practice Address - Zip Code:55308
Practice Address - Country:US
Practice Address - Phone:763-261-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRACARE CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-13
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NA197OtherPREF ONE
MN990228700Medicaid
86D71CEOtherBCBS
35580OtherHEALTH PARTNERS
98-00379OtherMEDICA
120173OtherUCARE
86D71CEOtherBCBS