Healthcare Provider Details

I. General information

NPI: 1932258845
Provider Name (Legal Business Name): NATIVE AMERICAN COMMUNITY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 09/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1213 E FRANKLIN AVE
MINNEAPOLIS MN
55404-2923
US

IV. Provider business mailing address

1213 E FRANKLIN AVE
MINNEAPOLIS MN
55404-2923
US

V. Phone/Fax

Practice location:
  • Phone: 612-872-8086
  • Fax: 612-872-8547
Mailing address:
  • Phone: 612-872-8086
  • Fax: 612-872-8547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State

VIII. Authorized Official

Name: LYDIA B CAROS
Title or Position: CEO
Credential: DO
Phone: 612-872-8086