Healthcare Provider Details

I. General information

NPI: 1962097683
Provider Name (Legal Business Name): GOOD CLINIC MN PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2021
Last Update Date: 03/04/2021
Certification Date: 02/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 1ST AVENUE
MINNEAPOLIS MN
55413-0000
US

IV. Provider business mailing address

307 1ST AVENUE
MINNEAPOLIS MN
55413
US

V. Phone/Fax

Practice location:
  • Phone: 952-653-2525
  • Fax: 952-653-2540
Mailing address:
  • Phone: 952-653-2525
  • Fax: 952-653-2540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: REBECCA HAFNER-FOGARTY
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 612-284-8206