Provider Demographics
NPI:1437218740
Name:SOUTHERN CITIES CLINIC
Entity type:Organization
Organization Name:SOUTHERN CITIES CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AMBULATORY CARE EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:507-985-2328
Mailing Address - Street 1:3200 LABORE RD STE 104
Mailing Address - Street 2:
Mailing Address - City:VADNAIS HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55110-5186
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 4TH ST NW
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-5031
Practice Address - Country:US
Practice Address - Phone:507-384-6830
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2025-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN496053000Medicaid