Healthcare Provider Details

I. General information

NPI: 1588004279
Provider Name (Legal Business Name): CRYSTAL NEW HOPE MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2013
Last Update Date: 06/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 DOUGLAS DR N
CRYSTAL MN
55422-2480
US

IV. Provider business mailing address

2904 JOHNSON ST NE
MINNEAPOLIS MN
55418-2234
US

V. Phone/Fax

Practice location:
  • Phone: 763-535-9601
  • Fax: 763-535-5601
Mailing address:
  • Phone: 612-782-0900
  • Fax: 612-788-4930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. MARGIE L EVENS
Title or Position: CEO
Credential:
Phone: 320-356-9141