Healthcare Provider Details

I. General information

NPI: 1669994315
Provider Name (Legal Business Name): CENTRACARE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2017
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 33RD ST S
SAINT CLOUD MN
56301-9668
US

IV. Provider business mailing address

PO BOX 735818
CHICAGO IL
60673-5818
US

V. Phone/Fax

Practice location:
  • Phone: 320-251-8181
  • Fax: 320-257-1733
Mailing address:
  • Phone:
  • Fax:

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 Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

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