Healthcare Provider Details

I. General information

NPI: 1043212665
Provider Name (Legal Business Name): CENTRACARE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 SIXTH AVE NO CENTRACARE CLINIC
ST CLOUD MN
56303-2735
US

IV. Provider business mailing address

PO BOX 735818
CHICAGO IL
60673-5818
US

V. Phone/Fax

Practice location:
  • Phone: 320-252-5131
  • Fax: 320-650-1777
Mailing address:
  • Phone: 320-252-5131
  • Fax: 320-650-1777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty 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: MICHAEL A BLAIR
Title or Position: SR VP & CFO
Credential:
Phone: 320-255-5665