Provider Demographics
NPI:1740798008
Name:ACE MEDICAL CENTER, LLC
Entity type:Organization
Organization Name:ACE MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:REGINE
Authorized Official - Middle Name:W
Authorized Official - Last Name:NDIFOR
Authorized Official - Suffix:
Authorized Official - Credentials:CNP RN
Authorized Official - Phone:617-413-4952
Mailing Address - Street 1:PO BOX 44044
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-1044
Mailing Address - Country:US
Mailing Address - Phone:617-413-4952
Mailing Address - Fax:
Practice Address - Street 1:10259 ENGLEWOOD DR
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55347-4623
Practice Address - Country:US
Practice Address - Phone:617-413-4952
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-19
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X, 261QC1500X, 261QP0904X, 261QP2300X, 261QU0200X
MN3233261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QP0904XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, Federal
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN=========OtherIRS