Healthcare Provider Details

I. General information

NPI: 1851388920
Provider Name (Legal Business Name): MEDCENTRA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 SMITH AVE N SUITE 301
SAINT PAUL MN
55102-2534
US

IV. Provider business mailing address

225 SMITH AVE N SUITE 301
SAINT PAUL MN
55102-2534
US

V. Phone/Fax

Practice location:
  • Phone: 651-288-5180
  • Fax: 651-288-5188
Mailing address:
  • Phone: 651-288-5180
  • Fax: 651-288-5188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State

VIII. Authorized Official

Name: MR. BRIAN DAVID SISKA
Title or Position: PRESIDENT/
Credential:
Phone: 763-545-3006