Provider Demographics
NPI:1821463860
Name:CENTRACARE CLINIC
Entity Type:Organization
Organization Name:CENTRACARE CLINIC
Other - Org Name:CENTRACARE CLINIC - MIDTOWN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-255-5665
Mailing Address - Street 1:3333 W DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-4515
Mailing Address - Country:US
Mailing Address - Phone:320-230-0590
Mailing Address - Fax:320-240-2053
Practice Address - Street 1:3333 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-4515
Practice Address - Country:US
Practice Address - Phone:320-230-0590
Practice Address - Fax:320-240-2053
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRACARE CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-12-02
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health