Healthcare Provider Details

I. General information

NPI: 1063762169
Provider Name (Legal Business Name): LIFE INSURANCE AGENCY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2012
Last Update Date: 03/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2489 RICE ST STE 295 SUITE 295
ROSEVILLE MN
55113-3738
US

IV. Provider business mailing address

2489 RICE ST STE 295 SUITE 295
ROSEVILLE MN
55113-3738
US

V. Phone/Fax

Practice location:
  • Phone: 952-388-7128
  • Fax: 800-532-1684
Mailing address:
  • Phone: 952-388-7128
  • Fax: 800-532-1684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateMN

VIII. Authorized Official

Name: MR. TUBTSHWM WASHINGTON YANG
Title or Position: PRESIDENT
Credential:
Phone: 952-388-7128