Healthcare Provider Details

I. General information

NPI: 1922416064
Provider Name (Legal Business Name): LIFECLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2014
Last Update Date: 07/31/2014
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: 952-229-7901
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number3112
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number8737
License Number StateMN

VIII. Authorized Official

Name: REZA ALIZADEH
Title or Position: CEO
Credential: DC
Phone: 612-868-6894