Healthcare Provider Details

I. General information

NPI: 1659323459
Provider Name (Legal Business Name): NEIGHBORHOOD HEALTHSOURCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 06/29/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10081 DOGWOOD ST. NW SUITE 100
COON RAPIDS MN
55448
US

IV. Provider business mailing address

2301 CENTRAL AVE NE
MINNEAPOLIS MN
55418
US

V. Phone/Fax

Practice location:
  • Phone: 612-588-9411
  • Fax: 763-783-7944
Mailing address:
  • Phone: 612-588-9411
  • Fax: 612-781-3837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MR. STEVEN JAY KNUTSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 612-287-2428