Provider Demographics
NPI:1104057926
Name:MANKATO CLINIC LTD
Entity type:Organization
Organization Name:MANKATO CLINIC LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:FARROW
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:800-657-6944
Mailing Address - Street 1:1230 E MAIN ST
Mailing Address - Street 2:PO BOX 8674
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-5066
Mailing Address - Country:US
Mailing Address - Phone:800-657-6944
Mailing Address - Fax:
Practice Address - Street 1:305 MAIN ST E
Practice Address - Street 2:
Practice Address - City:MAPLETON
Practice Address - State:MN
Practice Address - Zip Code:56065-2060
Practice Address - Country:US
Practice Address - Phone:507-524-3835
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MANKATO CLINIC LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-28
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN396510400Medicaid
MN396510400Medicaid
MNC06976Medicare PIN