Healthcare Provider Details

I. General information

NPI: 1740798008
Provider Name (Legal Business Name): ACE MEDICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2018
Last Update Date: 01/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10259 ENGLEWOOD DR
EDEN PRAIRIE MN
55347-4623
US

IV. Provider business mailing address

PO BOX 44044
EDEN PRAIRIE MN
55344-1044
US

V. Phone/Fax

Practice location:
  • Phone: 617-413-4952
  • Fax:
Mailing address:
  • Phone: 617-413-4952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP0904X
TaxonomyFederal Public Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number3233
License Number StateMN
# 6
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: REGINE W NDIFOR
Title or Position: ADMINISTRATOR
Credential: CNP RN
Phone: 617-413-4952