Healthcare Provider Details

I. General information

NPI: 1023456092
Provider Name (Legal Business Name): KANG LE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2013
Last Update Date: 04/17/2025
Certification Date: 04/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5593 W 78TH ST
EDINA MN
55439-2701
US

IV. Provider business mailing address

17814 STEADING RD
EDEN PRAIRIE MN
55347-2779
US

V. Phone/Fax

Practice location:
  • Phone: 612-208-3848
  • Fax:
Mailing address:
  • Phone: 612-384-5953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number1064338
License Number StateMN

VIII. Authorized Official

Name: LIXIN QIN
Title or Position: PRESIDENT
Credential: RN, L.AC
Phone: 612-208-3848