=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205940863
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEMORY CARE CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2006
-----------------------------------------------------
Last Update Date | 10/19/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2835 W SAINT GERMAIN ST
-----------------------------------------------------
City | SAINT CLOUD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56301-6280
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-257-1777
-----------------------------------------------------
Fax | 320-257-1776
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2835 W SAINT GERMAIN ST P.O. BOX 7776
-----------------------------------------------------
City | SAINT CLOUD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56301-6280
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-257-1777
-----------------------------------------------------
Fax | 320-257-1776
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | SANDRA L. WENNER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 320-257-1777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 1200898-2
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------