Provider Demographics
NPI:1255462487
Name:ANNEX TEEN CLINIC
Entity type:Organization
Organization Name:ANNEX TEEN CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:THOMPSON
Authorized Official - Last Name:MURRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-235-1980
Mailing Address - Street 1:5810 42ND AVENUE NORTH
Mailing Address - Street 2:
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422
Mailing Address - Country:US
Mailing Address - Phone:763-533-1316
Mailing Address - Fax:763-531-0315
Practice Address - Street 1:5810 42ND AVENUE NORTH
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422
Practice Address - Country:US
Practice Address - Phone:763-533-1316
Practice Address - Fax:763-531-0315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261QF0050X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN178182100Medicaid