Healthcare Provider Details

I. General information

NPI: 1821910134
Provider Name (Legal Business Name): NORTH STAR METABOLIC AND PERFORMANCE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 FRANCE AVE S STE 301
EDINA MN
55435-4505
US

IV. Provider business mailing address

16960 VALLEY RD
EDEN PRAIRIE MN
55347-2833
US

V. Phone/Fax

Practice location:
  • Phone: 952-800-3363
  • Fax:
Mailing address:
  • Phone: 661-703-3935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY LOUIS ROACH
Title or Position: PHYSICIAN/FOUNDER
Credential: MD
Phone: 661-703-3935