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General NPI Number Information
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NPI Number | 1659509180
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Entity Type | Organization
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Legal Business Name | CRESCENTERRA HEALTH CENTER, PA
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Dates
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Enumeration Date | 06/23/2009
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Last Update Date | 06/23/2009
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Provider Practice Location Address
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Address Line | 245 PRIOR AVE N
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City | SAINT PAUL
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State | MN
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Zip | 55104-5163
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Country | US
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Telephone | 651-917-3990
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Fax | 651-917-3922
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Provider Business Mailing Address
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Address Line | 245 PRIOR AVE N
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City | SAINT PAUL
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State | MN
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Zip | 55104-5163
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Country | US
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Telephone | 651-917-3990
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Fax | 651-917-3922
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Authorized Official
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Title or Position | PRESIDENT
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Name | MARY E RUTHERFORD
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Credential | DC
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Telephone | 651-917-3990
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 1853
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License Number State | MN
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