MEDICARE: COMMUNITY CARE CLINICS OF MINNESOTA

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	261Q00000X	Clinic/Center
2	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1417438169
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY CARE CLINICS OF MINNESOTA

Provider Business Mailing Address
First Line	:	2015 CHICAGO AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-2813
Country	:	US
Telephone Number	:	952-228-0420
Fax Number	:	612-345-4191

Provider Business Practice Location Address
First Line	:	2015 CHICAGO AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-2813
Country	:	US
Telephone Number	:	952-228-0420
Fax Number	:	612-345-4191

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	DR. ROBERT LARBI-ODAM
Credential	:
Telephone Number	:	952-228-0420

Provider Enumeration Date	:	08/21/2018
Last Update Date	:	07/06/2023

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