Provider Demographics
NPI:1932258845
Name:NATIVE AMERICAN COMMUNITY CLINIC
Entity Type:Organization
Organization Name:NATIVE AMERICAN COMMUNITY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:B
Authorized Official - Last Name:CAROS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:612-872-8086
Mailing Address - Street 1:1213 E FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-2923
Mailing Address - Country:US
Mailing Address - Phone:612-872-8086
Mailing Address - Fax:612-872-8547
Practice Address - Street 1:1213 E FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-2923
Practice Address - Country:US
Practice Address - Phone:612-872-8086
Practice Address - Fax:612-872-8547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN731188500Medicaid
MN241830Medicare PIN