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1555 Northway Drive Suite 200 St Cloud MN 56303-4913 | |
(320) 240-3157 | |
(320) 240-3143 |
Full Name | |
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Speciality | Clinic/center |
Location | 1555 Northway Drive, St Cloud, Minnesota |
Authorized Official Name and Position | Michael A. Blair (SR. VICE PRESIDENT AND CFO) |
Authorized Official Contact | 3202555665 |
Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
Mailing Address | Practice Location Address |
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1555 Northway Drive Suite 200 St Cloud MN 56303-4913 Ph: (320) 240-3157 | 1555 Northway Drive Suite 200 St Cloud MN 56303-4913 Ph: (320) 240-3157 |
NPI Number | 1770532426 |
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Provider Enumeration Date | 05/09/2006 |
Last Update Date | 10/10/2019 |
Identifier | Type | State | Issuer |
---|---|---|---|
1770532426 | NPI | - | NPPES |
616053100 | Medicaid | MN | |
690000070 | Other | MN | CENTRACARE LAB |
RR MEDICARE | Other | MN | 690009424 |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
261Q00000X | Clinic/center | 331506 (Minnesota) | Secondary |
261Q00000X | Clinic/center | (* (Not Available)) | Primary |