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General NPI Number Information
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NPI Number | 1407858020
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Entity Type | Organization
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Legal Business Name | CENTRACARE CLINIC
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Dates
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Enumeration Date | 08/12/2005
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Last Update Date | 11/19/2020
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Provider Practice Location Address
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Address Line | 1900 CENTRACARE CIR CENTRACARE CLINIC HEALTH PLAZA
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City | SAINT CLOUD
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State | MN
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Zip | 56303-5000
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Country | US
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Telephone | 320-252-2422
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Fax |
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Provider Business Mailing Address
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Address Line | 1200 6TH AVE N
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City | SAINT CLOUD
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State | MN
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Zip | 56303-2736
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Country | US
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Telephone | 320-229-4977
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Fax |
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Authorized Official
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Title or Position | SR VP & CFO
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Name | MICHAEL A BLAIR
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Credential |
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Telephone | 320-255-5665
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number | 411086657
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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