=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053347179
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SILVER LAKE CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2600 39TH AVE NE
-----------------------------------------------------
City | ST ANTHONY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55421-4372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-706-2900
-----------------------------------------------------
Fax | 612-706-2901
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2600 39TH AVE NE
-----------------------------------------------------
City | ST ANTHONY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55421-4372
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-706-2900
-----------------------------------------------------
Fax | 612-706-2901
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCIAL OFFICER, VP FINANCE
-----------------------------------------------------
Name | MR. PATRICK BORAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 763-520-5048
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------