Healthcare Provider Details

I. General information

NPI: 1023296167
Provider Name (Legal Business Name): LIFE CLINIC, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2008
Last Update Date: 08/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5525 CEDAR LAKE RD S
ST LOUIS PARK MN
55416-1420
US

IV. Provider business mailing address

33 HAMLINE AVE S
SAINT PAUL MN
55105-2231
US

V. Phone/Fax

Practice location:
  • Phone: 651-690-0866
  • Fax:
Mailing address:
  • Phone: 651-690-0866
  • Fax: 651-690-0031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number3221
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number8737
License Number StateMN

VIII. Authorized Official

Name: DR. REZA P ALIZADEH
Title or Position: CHIROPRACTOR
Credential: D.C.
Phone: 612-868-6894