Healthcare Provider Details

I. General information

NPI: 1942431242
Provider Name (Legal Business Name): ST. CLOUD VAMC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2009
Last Update Date: 06/21/2023
Certification Date: 06/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 30TH AVE E
ALEXANDRIA MN
56308-4769
US

IV. Provider business mailing address

PO BOX 94461
CLEVELAND OH
44101-4461
US

V. Phone/Fax

Practice location:
  • Phone: 913-578-4409
  • Fax:
Mailing address:
  • Phone: 913-578-4409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ERIN POTTER
Title or Position: NPI TEAM
Credential:
Phone: 202-382-2579