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General NPI Number Information
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NPI Number | 1033284146
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Entity Type | Organization
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Legal Business Name | SELS SENIOR EXERCISE LIFESTYLE SERVICES
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Dates
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Enumeration Date | 11/22/2006
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Last Update Date | 06/16/2008
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Provider Practice Location Address
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Address Line | 5950 CHURCHILL ST
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City | SHOREVIEW
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State | MN
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Zip | 55126-8427
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Country | US
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Telephone | 651-208-4564
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Fax | 651-774-2107
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Provider Business Mailing Address
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Address Line | 1044 CENTERVILLE CIR SUITE 200
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City | VADNAIS HEIGHTS
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State | MN
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Zip | 55127-6346
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Country | US
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Telephone | 651-774-2107
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Fax | 651-774-1098
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Authorized Official
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Title or Position | PRESIDENT
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Name | SANDRA SWAMI
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Credential | CES
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Telephone | 651-208-4564
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number | C10380
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License Number State | MN
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