Healthcare Provider Details

I. General information

NPI: 1972860526
Provider Name (Legal Business Name): LIFETREE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2012
Last Update Date: 04/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14585 GRAND AVE SUITE 206
BURNSVILLE MN
55306-5719
US

IV. Provider business mailing address

14585 GRAND AVE SUITE 206
BURNSVILLE MN
55306-5719
US

V. Phone/Fax

Practice location:
  • Phone: 952-435-7349
  • Fax: 952-417-6159
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1529
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number0082
License Number StateMN

VIII. Authorized Official

Name: KYU HONG TAE
Title or Position: OWNER
Credential: L.AC.
Phone: 612-723-2042