MEDICARE: CLARKE A. MCKINNEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1003814161
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLARKE A. MCKINNEY

Provider Business Mailing Address
First Line	:	4711 CLARK AVE
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-3268
Country	:	US
Telephone Number	:	651-429-6323
Fax Number	:	651-426-2046

Provider Business Practice Location Address
First Line	:	4711 CLARK AVE
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-3268
Country	:	US
Telephone Number	:	651-429-6323
Fax Number	:	651-426-2046

Authorized Official
Title or Position	:	OWNER
Name	:	MR. CLARKE A MCKINNEY
Credential	:
Telephone Number	:	651-429-6323

Provider Enumeration Date	:	07/12/2005
Last Update Date	:	08/22/2020

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