NPIMap

Organization Active NPI

Native American Community Clinic

  • Community/Behavioral Health Agency
  • Minneapolis, MN
National Provider Identifier
1730366600
Registry record updated Sep 15, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Behavioral Health AgencyTaxonomy code 251S00000X
Legal business name
NATIVE AMERICAN COMMUNITY CLINIC
Practice address
1213 E Franklin Ave
Minneapolis, MN 55404-2923
Phone
(612) 872-8086
Fax
(612) 872-8547
NPI assigned
Jan 23, 2008
Organization subpart
Yes
Parent organization
NATIVE AMERICAN COMMUNITY CLINICAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Sep 15, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Lydia Beth Caros, D.O
Title
Ceo
Phone
(612) 872-8086

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Community/Behavioral Health Agency 251S00000X Primary

Addresses

Primary practice location

1213 E Franklin Ave
Minneapolis, MN 55404-2923

Mailing address

1213 E Franklin Ave
Minneapolis, MN 55404-2923
Phone (612) 872-8086

Other identifiers 1

IdentifierTypeStateIssuer
596112000MedicaidMN

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040205000844 MN Part B Supplier - Clinic/Group Practice 8224921978 Receives reassigned benefits from 16 practitioners
1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Minneapolis, MN
O20200706001319 MN Part A Provider - Federally Qualified Health Center (FQHC) 8224921978 Practice locations: Minneapolis, MN

Federally qualified health center certification: CCN 241889

Legal name
NATIVE AMERICAN COMMUNITY CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jul 6, 2020
Last certification
Jul 6, 2020
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jun 4, 2002 in MN
Enrollment address
1213 E Franklin Ave
Minneapolis, MN 55404-2923

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Part of
Native American Community

Locations

3131 19th Ave S
Ofc 238D
Minneapolis, MN 55407
Phone (612) 872-8086

1113 E Franklin Ave
Ste 103
Minneapolis, MN 55404
Phone (612) 259-8526

2421 Bloomington Ave
Rm Art
Minneapolis, MN 55404
Phone (612) 872-8086

Ownership & related parties

All disclosed owners & managing parties 3

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Amy Perunovich Individual W-2 Managing Employee Jun 1, 2012
Antony Stately Individual Corporate OfficerCeo Jan 1, 2017
Stepahnie Graves Individual Corporate Director Jul 25, 2019

Practitioners & affiliated clinicians

Practitioners 16

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 16

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1201046400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1442275200000",
    "number": "1730366600",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1213 E FRANKLIN AVE",
            "city": "MINNEAPOLIS",
            "state": "MN",
            "postal_code": "554042923",
            "telephone_number": "612-872-8086",
            "fax_number": "612-872-8547"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1213 E FRANKLIN AVE",
            "city": "MINNEAPOLIS",
            "state": "MN",
            "postal_code": "554042923",
            "telephone_number": "612-872-8086",
            "fax_number": "612-872-8547"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NATIVE AMERICAN COMMUNITY CLINIC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "NATIVE AMERICAN COMMUNITY CLINIC",
        "enumeration_date": "2008-01-23",
        "last_updated": "2015-09-15",
        "status": "A",
        "authorized_official_last_name": "CAROS",
        "authorized_official_first_name": "LYDIA",
        "authorized_official_middle_name": "BETH",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "612-872-8086",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "D.O"
    },
    "taxonomies": [
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "596112000",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Minneapolis, MN

Sources for this page

Verify at the official NPI Registry.