1508067414 NPI number — THREE RIVERS CLINIC, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508067414 NPI number — THREE RIVERS CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THREE RIVERS CLINIC, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508067414
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6311 WAYZATA BLVD
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55416-1209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-545-0200
Provider Business Mailing Address Fax Number:
952-545-6388

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6311 WAYZATA BLVD
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55416-1209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-545-0200
Provider Business Practice Location Address Fax Number:
952-545-6388
Provider Enumeration Date:
05/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BEHNKE
Authorized Official First Name:
JILL
Authorized Official Middle Name:
ROBYN
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
952-545-0200

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  1071 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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