Healthcare Provider Details

I. General information

NPI: 1982882742
Provider Name (Legal Business Name): NUCLEUS CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2008
Last Update Date: 02/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1323 COON RAPIDS BLVD NW
COON RAPIDS MN
55433-5362
US

IV. Provider business mailing address

1323 COON RAPIDS BLVD NW
COON RAPIDS MN
55433-5362
US

V. Phone/Fax

Practice location:
  • Phone: 763-755-5300
  • Fax: 763-755-5301
Mailing address:
  • Phone: 763-755-5300
  • Fax: 763-755-5301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State

VIII. Authorized Official

Name: DIANE LYNN HENDRICKSON
Title or Position: CHEIF EXECUTIVE OFFICER
Credential: CEO
Phone: 763-755-5300