Healthcare Provider Details

I. General information

NPI: 1073907606
Provider Name (Legal Business Name): LOUIS NEWSTROM LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2015
Last Update Date: 03/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 VINEWOOD LN N
PLYMOUTH MN
55441-1155
US

IV. Provider business mailing address

1404 LAKE ST NE
HOPKINS MN
55343-1908
US

V. Phone/Fax

Practice location:
  • Phone: 763-559-9236
  • Fax:
Mailing address:
  • Phone: 763-614-0363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number00030348
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: