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General NPI Number Information
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NPI Number | 1578116786
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Entity Type | Organization
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Legal Business Name | ADVACARE MEDICAL CLINIC LTD
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Dates
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Enumeration Date | 07/17/2019
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Last Update Date | 07/17/2019
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Provider Practice Location Address
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Address Line | 5325 W 74TH ST STE 9
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City | EDINA
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State | MN
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Zip | 55439-2212
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Country | US
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Telephone | 651-354-6602
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Fax |
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Provider Business Mailing Address
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Address Line | 1359 KNOLL DR
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City | SHAKOPEE
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State | MN
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Zip | 55379-4624
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | DAVID MAKONDE OGATO
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Credential | CNP
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Telephone | 651-354-6602
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QG0250X
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Taxonomy Name | Genetics Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QP3300X
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Taxonomy Name | Pain 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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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