Healthcare Provider Details

I. General information

NPI: 1225158520
Provider Name (Legal Business Name): CHILD AND TEEN MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 08/24/2021
Certification Date: 08/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11107 ULYSSES ST NE STE 100
BLAINE MN
55434-4184
US

IV. Provider business mailing address

11107 ULYSSES ST NE STE 100
BLAINE MN
55434-4184
US

V. Phone/Fax

Practice location:
  • Phone: 763-333-7733
  • Fax: 763-333-7711
Mailing address:
  • Phone: 763-333-7733
  • Fax: 763-333-7711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. ANGELA MARIE BENNETT
Title or Position: PRACTIC ADMINISTRATOR
Credential: BA
Phone: 763-333-7755