Healthcare Provider Details

I. General information

NPI: 1033284146
Provider Name (Legal Business Name): SELS SENIOR EXERCISE LIFESTYLE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5950 CHURCHILL ST
SHOREVIEW MN
55126-8427
US

IV. Provider business mailing address

1044 CENTERVILLE CIR SUITE 200
VADNAIS HEIGHTS MN
55127-6346
US

V. Phone/Fax

Practice location:
  • Phone: 651-208-4564
  • Fax: 651-774-2107
Mailing address:
  • Phone: 651-774-2107
  • Fax: 651-774-1098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License NumberC10380
License Number StateMN

VIII. Authorized Official

Name: SANDRA SWAMI
Title or Position: PRESIDENT
Credential: CES
Phone: 651-208-4564