Basic Information
| Provider Information | |||||||||
| NPI: | 1538696323 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRACARE CLINIC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | CENTRACARE QUICKCLINIC - SARTELL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1725 PINE CONE RD S | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | SARTELL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563775801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206567129 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1200 6TH AVE N | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202525131 | ||||||||
| FaxNumber: | 3202402118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2017 | ||||||||
| LastUpdateDate: | 05/11/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FELDHEGE | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | TREAS/DIR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 3202402152 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | MN | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.