Provider Demographics
NPI:1457088809
Name:MINA MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:MINA MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:IDIRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ESSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-274-4380
Mailing Address - Street 1:6417 PENN AVE S STE 8
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55423-1196
Mailing Address - Country:US
Mailing Address - Phone:612-274-4380
Mailing Address - Fax:
Practice Address - Street 1:1690 SILVER LAKE ROAD NW
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112
Practice Address - Country:US
Practice Address - Phone:612-274-4380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-05
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center