Healthcare Provider Details

I. General information

NPI: 1710257860
Provider Name (Legal Business Name): OPEN DOOR HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2012
Last Update Date: 04/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 HOLLY LN
MANKATO MN
56001-5422
US

IV. Provider business mailing address

309 HOLLY LN
MANKATO MN
56001-5422
US

V. Phone/Fax

Practice location:
  • Phone: 507-388-2120
  • Fax: 507-388-3924
Mailing address:
  • Phone: 507-388-2120
  • Fax: 507-388-3924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. DOUGLAS L JAEGER JR.
Title or Position: CEO
Credential:
Phone: 507-344-5500