Provider Demographics
NPI:1053704635
Name:CENTRAL MEDICAL CLINIC, PLLC.
Entity type:Organization
Organization Name:CENTRAL MEDICAL CLINIC, PLLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MORALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-644-6002
Mailing Address - Street 1:393 DUNLAP ST N
Mailing Address - Street 2:LL34
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-4200
Mailing Address - Country:US
Mailing Address - Phone:651-644-6002
Mailing Address - Fax:651-647-1647
Practice Address - Street 1:393 DUNLAP ST N
Practice Address - Street 2:LL34
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4200
Practice Address - Country:US
Practice Address - Phone:651-644-6002
Practice Address - Fax:651-647-1647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-06
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1123204363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty