Provider Demographics
NPI:1265549927
Name:EXPRESS HEALTHCARE
Entity type:Organization
Organization Name:EXPRESS HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:763-795-9363
Mailing Address - Street 1:10190 BALTIMORE ST NE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-5056
Mailing Address - Country:US
Mailing Address - Phone:763-795-9363
Mailing Address - Fax:763-795-9364
Practice Address - Street 1:10190 BALTIMORE ST NE
Practice Address - Street 2:SUITE 110
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-5056
Practice Address - Country:US
Practice Address - Phone:763-795-9363
Practice Address - Fax:763-795-9364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1639261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC03507Medicare ID - Type Unspecified