Healthcare Provider Details

I. General information

NPI: 1457456691
Provider Name (Legal Business Name): CATALYST MEDICAL CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 03/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 LEWIS AVE S STE 201
WATERTOWN MN
55388-4502
US

IV. Provider business mailing address

29 E MAIN ST
WACONIA MN
55387-1114
US

V. Phone/Fax

Practice location:
  • Phone: 952-955-1963
  • Fax: 952-955-1965
Mailing address:
  • Phone: 952-442-7015
  • Fax: 952-442-7016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number1540
License Number StateMN

VIII. Authorized Official

Name: SCOTT M JENSEN
Title or Position: PRESIDENT/OWNER
Credential: MD
Phone: 952-955-1963