Provider Demographics
NPI:1962097683
Name:GOOD CLINIC MN PLLC
Entity type:Organization
Organization Name:GOOD CLINIC MN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAFNER-FOGARTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-284-8206
Mailing Address - Street 1:307 1ST AVENUE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413
Mailing Address - Country:US
Mailing Address - Phone:952-653-2525
Mailing Address - Fax:952-653-2540
Practice Address - Street 1:307 1ST AVENUE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-0000
Practice Address - Country:US
Practice Address - Phone:952-653-2525
Practice Address - Fax:952-653-2540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-04
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site