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General NPI Number Information
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NPI Number | 1174836597
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Entity Type | Organization
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Legal Business Name | LITTLE CANADA MEDICAL CLINIC
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Dates
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Enumeration Date | 07/15/2010
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Last Update Date | 07/15/2010
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Provider Practice Location Address
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Address Line | 75 LITTLE CANADA RD W
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City | LITTLE CANADA
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State | MN
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Zip | 55117-1362
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Country | US
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Telephone | 651-481-1119
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Fax | 651-481-1476
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Provider Business Mailing Address
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Address Line | 75 LITTLE CANADA RD W
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City | LITTLE CANADA
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State | MN
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Zip | 55117-1362
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Country | US
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Telephone | 651-481-1119
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Fax | 651-481-1476
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JAMES WILLIAM ALLAN
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Credential | M.D.
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Telephone | 651-481-1119
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 20780
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License Number State | MN
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