Healthcare Provider Details

I. General information

NPI: 1437499019
Provider Name (Legal Business Name): THE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2013
Last Update Date: 02/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 JEFFERSON ST S
WADENA MN
56482-1532
US

IV. Provider business mailing address

40734 COUNTY 1
BERTHA MN
56437-1019
US

V. Phone/Fax

Practice location:
  • Phone: 218-640-2647
  • Fax: 218-461-4558
Mailing address:
  • Phone: 218-640-2647
  • Fax: 218-461-4558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QF0050X
TaxonomyNon-Surgical Family Planning Clinic/Center
License NumberR1769683
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberR1769683
License Number StateMN

VIII. Authorized Official

Name: ROBIN S COLBURN
Title or Position: OWNER
Credential: CNM
Phone: 218-640-2647