Healthcare Provider Details

I. General information

NPI: 1013104348
Provider Name (Legal Business Name): CENTRACARE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2007
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16830 198TH AVE NW CENTRACARE CLINIC - BIG LAKE
BIG LAKE MN
55309-4860
US

IV. Provider business mailing address

1200 6TH AVE N
SAINT CLOUD MN
56303-2736
US

V. Phone/Fax

Practice location:
  • Phone: 763-263-7300
  • Fax: 763-263-7338
Mailing address:
  • Phone: 320-229-4977
  • Fax: 763-263-7338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL A BLAIR
Title or Position: SR VP & CFO
Credential:
Phone: 320-255-5665