Healthcare Provider Details

I. General information

NPI: 1255939716
Provider Name (Legal Business Name): KINGSLEY CLINIC OF MINNESOTA, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2020
Last Update Date: 04/26/2023
Certification Date: 04/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 WASHINGTON AVE N STE 300
MINNEAPOLIS MN
55401-1353
US

IV. Provider business mailing address

333 WASHINGTON AVE N STE 300
MINNEAPOLIS MN
55401-1353
US

V. Phone/Fax

Practice location:
  • Phone: 612-453-1907
  • Fax: 612-500-4916
Mailing address:
  • Phone: 612-453-1907
  • Fax: 612-500-4916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JAMES KINGSLEY
Title or Position: OWNER
Credential: MD
Phone: 612-453-1907