Healthcare Provider Details

I. General information

NPI: 1023742350
Provider Name (Legal Business Name): LIONS UNITED FITNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2022
Last Update Date: 07/12/2022
Certification Date: 07/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2535 PILOT KNOB RD STE 126
MENDOTA HEIGHTS MN
55120-1170
US

IV. Provider business mailing address

2535 PILOT KNOB RD STE 126
MENDOTA HEIGHTS MN
55120-1170
US

V. Phone/Fax

Practice location:
  • Phone: 651-348-7278
  • Fax:
Mailing address:
  • Phone: 651-348-7278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANDREW ROBERT CAMERON
Title or Position: LIFE COACH
Credential:
Phone: 651-348-7278