=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356903827
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAIN STREET CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2019
-----------------------------------------------------
Last Update Date | 07/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 107 WEST 4TH ST
-----------------------------------------------------
City | WINONA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55987
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-454-3650
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 855 MANKATO AVE
-----------------------------------------------------
City | WINONA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55987-4868
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-454-3650
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | RACHELLE HEISING SCHULTZ
-----------------------------------------------------
Credential | ED.D
-----------------------------------------------------
Telephone | 507-454-3650
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------