Healthcare Provider Details

I. General information

NPI: 1174836597
Provider Name (Legal Business Name): LITTLE CANADA MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2010
Last Update Date: 07/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 LITTLE CANADA RD W
LITTLE CANADA MN
55117-1362
US

IV. Provider business mailing address

75 LITTLE CANADA RD W
LITTLE CANADA MN
55117-1362
US

V. Phone/Fax

Practice location:
  • Phone: 651-481-1119
  • Fax: 651-481-1476
Mailing address:
  • Phone: 651-481-1119
  • Fax: 651-481-1476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number20780
License Number StateMN

VIII. Authorized Official

Name: DR. JAMES WILLIAM ALLAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 651-481-1119