Provider Demographics
NPI:1457437907
Name:FRIDLEY TARGET CLINIC
Entity Type:Organization
Organization Name:FRIDLEY TARGET CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:MILLICENT
Authorized Official - Middle Name:
Authorized Official - Last Name:WANJOHI
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:763-571-9361
Mailing Address - Street 1:12375 OAK PARK BLVD NE
Mailing Address - Street 2:APT # 206
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-7302
Mailing Address - Country:US
Mailing Address - Phone:763-862-9656
Mailing Address - Fax:
Practice Address - Street 1:755 53RD AVE NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55421-1240
Practice Address - Country:US
Practice Address - Phone:763-571-9361
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN935261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care