Healthcare Provider Details

I. General information

NPI: 1851695514
Provider Name (Legal Business Name): CEDAR RIVERSIDE PEOPLE'S CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2011
Last Update Date: 06/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 CHICAGO AVENUE
MINNEAPOLIS MN
55404-3845
US

IV. Provider business mailing address

425 20TH AVENUE SOUTH
MINNEAPOLIS MN
55454-4400
US

V. Phone/Fax

Practice location:
  • Phone: 612-332-4973
  • Fax: 612-238-3534
Mailing address:
  • Phone: 612-332-4973
  • Fax: 612-238-3534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateMN

VIII. Authorized Official

Name: MRS. SAHRA NOOR
Title or Position: CEO
Credential:
Phone: 612-332-4973