Healthcare Provider Details

I. General information

NPI: 1093994030
Provider Name (Legal Business Name): CHILDREN'S HEALTH CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2007
Last Update Date: 10/31/2022
Certification Date: 10/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 CHICAGO AVE. S.
MINNEAPOLIS MN
55404-4518
US

IV. Provider business mailing address

5901 LINCOLN DRIVE, CBC-2-REV/PE
EDINA MN
55436-1611
US

V. Phone/Fax

Practice location:
  • Phone: 612-813-6000
  • Fax:
Mailing address:
  • Phone: 952-992-5691
  • Fax: 952-992-6917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRENDA LU ALEXANDER MCCORMICK
Title or Position: SR. VP AND CHIEF FINANCIAL OFFICER
Credential:
Phone: 612-813-6129