Healthcare Provider Details

I. General information

NPI: 1457405763
Provider Name (Legal Business Name): CENTRACARE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 09/10/2024
Certification Date: 02/13/2020
Deactivation Date: 02/13/2020
Reactivation Date: 09/10/2024

III. Provider practice location address

1900 CENTRACARE CIR SUITE 1450
SAINT CLOUD MN
56303-5000
US

IV. Provider business mailing address

1900 CENTRACARE CIR SUITE 1450
SAINT CLOUD MN
56303-5000
US

V. Phone/Fax

Practice location:
  • Phone: 320-229-4917
  • Fax:
Mailing address:
  • Phone: 320-229-4917
  • Fax: 320-229-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: THOMAS M FELDHEGE
Title or Position: CFO/TREASURER
Credential:
Phone: 320-240-2152