Healthcare Provider Details

I. General information

NPI: 1104850510
Provider Name (Legal Business Name): HENDRICKS CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 12/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 E LINCOLN ST
HENDRICKS MN
56136-0026
US

IV. Provider business mailing address

501 E LINCOLN ST PO BOX 26
HENDRICKS MN
56136-0026
US

V. Phone/Fax

Practice location:
  • Phone: 507-275-3121
  • Fax: 507-275-3194
Mailing address:
  • Phone: 507-275-3121
  • Fax: 507-275-3194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number1757969
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. TABB L MCCLUSKEY
Title or Position: OWNER PRESIDENT
Credential: DO
Phone: 507-275-3121