MEDICARE: SOUTHERN CITIES CLINIC

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	1223D0001X	Public Health Dentistry

General Provider Information

NPI Number	:	1326904756
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN CITIES CLINIC

Provider Business Mailing Address
First Line	:	3200 LABORE RD STE 104
Second Line	:
City	:	VADNAIS HEIGHTS
State	:	MN
Zip	:	55110-5186
Country	:	US
Telephone Number	:	651-539-7200
Fax Number	:	651-431-7505

Provider Business Practice Location Address
First Line	:	400 4TH ST NW STE A
Second Line	:
City	:	FARIBAULT
State	:	MN
Zip	:	55021-5090
Country	:	US
Telephone Number	:	507-384-6830
Fax Number	:	651-431-7757

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR AMBULATORY SERVI
Name	:	MELISSA ELLS
Credential	:	PHARMD
Telephone Number	:	651-539-7200

Provider Enumeration Date	:	12/30/2025
Last Update Date	:	01/28/2026

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Directions to “SOUTHERN CITIES CLINIC ” Practice Location

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