Provider Demographics
NPI:1255939716
Name:KINGSLEY CLINIC OF MINNESOTA, PLLC
Entity type:Organization
Organization Name:KINGSLEY CLINIC OF MINNESOTA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:KINGSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-453-1907
Mailing Address - Street 1:333 WASHINGTON AVE N STE 300
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55401-1353
Mailing Address - Country:US
Mailing Address - Phone:612-453-1907
Mailing Address - Fax:612-500-4916
Practice Address - Street 1:333 WASHINGTON AVE N STE 300
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55401-1353
Practice Address - Country:US
Practice Address - Phone:612-453-1907
Practice Address - Fax:612-500-4916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-15
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty