=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245972462
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHRISTINA CLINIC, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2022
-----------------------------------------------------
Last Update Date | 04/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2338 NO. LEXINGTON AVE
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-482-8912
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 905 1ST ST. NO.
-----------------------------------------------------
City | STILLWATER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55082
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-485-4607
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | CHRISTINE SPLINTER CAIRL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 651-485-4607
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 247200000X
-----------------------------------------------------
Taxonomy Name | Other Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------