Provider Demographics
NPI:1982441853
Name:CENTRACARE CLINIC SOUTHWEST LLC
Entity type:Organization
Organization Name:CENTRACARE CLINIC SOUTHWEST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. DIRECTOR OF CLINICS
Authorized Official - Prefix:
Authorized Official - First Name:CARYN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGREARY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-354-2222
Mailing Address - Street 1:6501 CITY WEST PKWY
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-3248
Mailing Address - Country:US
Mailing Address - Phone:952-653-2525
Mailing Address - Fax:
Practice Address - Street 1:600 PETERSON PKWY
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:MN
Practice Address - Zip Code:56273-7823
Practice Address - Country:US
Practice Address - Phone:320-354-2222
Practice Address - Fax:320-354-2274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site