Provider Demographics
NPI:1245682905
Name:OPEN DOOR HEALTH CENTER
Entity type:Organization
Organization Name:OPEN DOOR HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:JAEGER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:507-344-5500
Mailing Address - Street 1:309 HOLLY LN
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-5422
Mailing Address - Country:US
Mailing Address - Phone:507-388-2120
Mailing Address - Fax:507-388-8351
Practice Address - Street 1:1025 10TH AVE
Practice Address - Street 2:
Practice Address - City:CLARKFIELD
Practice Address - State:MN
Practice Address - Zip Code:56223-1301
Practice Address - Country:US
Practice Address - Phone:320-669-7564
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-06
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261QF0400X1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN201094100Medicaid
MN241857Medicare Oscar/Certification