Provider Demographics
NPI:1265626964
Name:MANKATO CLINIC EXPRESS, LLC
Entity type:Organization
Organization Name:MANKATO CLINIC EXPRESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:FARROW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-389-8501
Mailing Address - Street 1:1850 ADAMS ST
Mailing Address - Street 2:SUITE 130
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-4864
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1850 ADAMS ST
Practice Address - Street 2:SUITE 130
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-4864
Practice Address - Country:US
Practice Address - Phone:507-625-1811
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-05
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty