Healthcare Provider Details

I. General information

NPI: 1578116786
Provider Name (Legal Business Name): ADVACARE MEDICAL CLINIC LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2019
Last Update Date: 07/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5325 W 74TH ST STE 9
EDINA MN
55439-2212
US

IV. Provider business mailing address

1359 KNOLL DR
SHAKOPEE MN
55379-4624
US

V. Phone/Fax

Practice location:
  • Phone: 651-354-6602
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QG0250X
TaxonomyGenetics Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DAVID MAKONDE OGATO
Title or Position: PRACTICE MANAGER
Credential: CNP
Phone: 651-354-6602