Healthcare Provider Details

I. General information

NPI: 1053704635
Provider Name (Legal Business Name): CENTRAL MEDICAL CLINIC, PLLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2015
Last Update Date: 03/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

393 DUNLAP ST N LL34
SAINT PAUL MN
55104-4200
US

IV. Provider business mailing address

393 DUNLAP ST N LL34
SAINT PAUL MN
55104-4200
US

V. Phone/Fax

Practice location:
  • Phone: 651-644-6002
  • Fax: 651-647-1647
Mailing address:
  • Phone: 651-644-6002
  • Fax: 651-647-1647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1123204
License Number StateMN

VIII. Authorized Official

Name: MRS. CHRISTINE MORALES
Title or Position: CLINIC DIRECTOR
Credential:
Phone: 651-644-6002