Provider Demographics
NPI:1730366600
Name:NATIVE AMERICAN COMMUNITY CLINIC
Entity type:Organization
Organization Name:NATIVE AMERICAN COMMUNITY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:CAROS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:612-872-8086
Mailing Address - Street 1:1213 E FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-2923
Mailing Address - Country:US
Mailing Address - Phone:612-872-8086
Mailing Address - Fax:612-872-8547
Practice Address - Street 1:1213 E FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-2923
Practice Address - Country:US
Practice Address - Phone:612-872-8086
Practice Address - Fax:612-872-8547
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NATIVE AMERICAN COMMUNITY CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-23
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN596112000Medicaid