Provider Demographics
NPI:1851695514
Name:CEDAR RIVERSIDE PEOPLE'S CENTER
Entity Type:Organization
Organization Name:CEDAR RIVERSIDE PEOPLE'S CENTER
Other - Org Name:CHICAGO AVENUE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:SAHRA
Authorized Official - Middle Name:
Authorized Official - Last Name:NOOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-332-4973
Mailing Address - Street 1:425 20TH AVENUE SOUTH
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55454-4400
Mailing Address - Country:US
Mailing Address - Phone:612-332-4973
Mailing Address - Fax:612-238-3534
Practice Address - Street 1:2425 CHICAGO AVENUE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3845
Practice Address - Country:US
Practice Address - Phone:612-332-4973
Practice Address - Fax:612-238-3534
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CEDAR RIVERSIDE PEOPLE'S CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-10
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207QA0000X
MN261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent MedicineGroup - Single Specialty