Basic Information
| Provider Information | |||||||||
| NPI: | 1710257860 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OPEN DOOR HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OPEN DOOR HEALTH CENTER - MOBILE MEDICAL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 309 HOLLY LN | ||||||||
| Address2: | |||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560015422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073882120 | ||||||||
| FaxNumber: | 5073883924 | ||||||||
| Practice Location | |||||||||
| Address1: | 309 HOLLY LN | ||||||||
| Address2: | |||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560015422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073882120 | ||||||||
| FaxNumber: | 5073883924 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2012 | ||||||||
| LastUpdateDate: | 04/04/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JAEGER | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5073445500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.