NPIMap

Organization Active NPI

Native American Community Clinic

  • Public Health or Welfare Agency
  • Minneapolis, MN
National Provider Identifier
1932258845
Registry record updated Sep 16, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Public Health or Welfare AgencyTaxonomy code 251K00000X
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 9, 2007
Last updated
Sep 16, 2015By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 16, 2015

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

Authorized official

Name
Lydia B Caros, DONPI 1770519571
Title
Ceo
Phone
(612) 872-8086

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Public Health or Welfare Agency 251K00000X NU 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
731188500MedicaidMN

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
Practice locations: Minneapolis, MN
O20040515000093 MN Part A Provider - Federally Qualified Health Center (FQHC) 8224921978 Practice locations: Minneapolis, MN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1932258845. Details of each certification follow.

Federally qualified health center certification: CCN 241830

Legal name
NATIVE AMERICAN COMMUNITY CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 25, 2004
Last certification
Jun 25, 2004
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Oct 1, 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
Tax ID family
Native American Community2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 8

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

NameRoleSinceShare
Misty Blue Individual Corporate Director Feb 28, 2018
Anna Youngerman Individual Corporate Director Jun 28, 2018
Jean Forster Individual Corporate Director Sep 1, 2012
Joe Hobot Individual Corporate Director Jan 25, 2017
Lyle Harvey Iron Mocassin Individual Corporate Director Jun 9, 2004
Antony Stately Individual Corporate OfficerCeo Dec 13, 2016
W-2 Managing EmployeeCeo Dec 13, 2016
Billy Crofut Individual Corporate Director Aug 1, 2018
Patina Park Individual Corporate Director Nov 30, 2018

Practitioners & affiliated clinicians

Practitioners 17

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 17

NPI Registry JSON

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

{
    "created_epoch": "1168300800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1442361600000",
    "number": "1932258845",
    "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": "NO",
        "enumeration_date": "2007-01-09",
        "last_updated": "2015-09-16",
        "status": "A",
        "authorized_official_last_name": "CAROS",
        "authorized_official_first_name": "LYDIA",
        "authorized_official_middle_name": "B",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "612-872-8086",
        "authorized_official_credential": "DO"
    },
    "taxonomies": [
        {
            "code": "251K00000X",
            "taxonomy_group": "",
            "desc": "Public Health or Welfare",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "731188500",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Minneapolis, MN

Sources for this page

Verify at the official NPI Registry.