=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053044149
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PIIC CLINICAL SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2022
-----------------------------------------------------
Last Update Date | 03/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4321 109TH AVE NE
-----------------------------------------------------
City | BLAINE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55449-6794
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-698-9860
-----------------------------------------------------
Fax | 833-972-1581
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 323 WASHINGTON AVE N STE 200
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55401-2206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-698-9860
-----------------------------------------------------
Fax | 612-930-0106
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CARE OPERATIONS MANAGER
-----------------------------------------------------
Name | ALETHEA ANDERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 952-698-9860
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------