Healthcare Provider Details

I. General information

NPI: 1164978219
Provider Name (Legal Business Name): CENTRACARE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2016
Last Update Date: 06/23/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3701 12TH ST N SUITE 100
SAINT CLOUD MN
56303-2255
US

IV. Provider business mailing address

1200 6TH AVE N
SAINT CLOUD MN
56303-2735
US

V. Phone/Fax

Practice location:
  • Phone: 320-253-7257
  • Fax: 320-251-2938
Mailing address:
  • Phone: 320-252-5131
  • Fax: 320-240-2118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MICHAEL A BLAIR
Title or Position: SR VP & CFO
Credential:
Phone: 320-255-5665