Healthcare Provider Details

I. General information

NPI: 1265703078
Provider Name (Legal Business Name): CLASSIC HEALTH CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2012
Last Update Date: 01/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4748 CHICAGO AVE SUITE #10
MINNEAPOLIS MN
55407-3515
US

IV. Provider business mailing address

4748 CHICAGO AVE SUITE #10
MINNEAPOLIS MN
55407-3515
US

V. Phone/Fax

Practice location:
  • Phone: 612-916-0774
  • Fax:
Mailing address:
  • Phone: 612-916-0774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GRETCHEN E PORTER
Title or Position: OWNER
Credential: ANP, LAC
Phone: 612-916-0774