Healthcare Provider Details

I. General information

NPI: 1750759072
Provider Name (Legal Business Name): LIVE HEALTHY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2015
Last Update Date: 02/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 147TH ST W UNIT 304
APPLE VALLEY MN
55124-7541
US

IV. Provider business mailing address

7300 147TH ST W UNIT 304
APPLE VALLEY MN
55124-7541
US

V. Phone/Fax

Practice location:
  • Phone: 952-431-5330
  • Fax: 651-528-6882
Mailing address:
  • Phone: 952-431-5330
  • Fax: 651-528-6882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2728
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number2728
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number43602
License Number StateMN
# 4
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number43602
License Number StateMN

VIII. Authorized Official

Name: DR. CHRISTOPHER PAUL MASSOGLIA SR.
Title or Position: PRESIDENT
Credential: DC
Phone: 651-334-1290