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1588568505 NPI number — LONGEVITY WEIGHT MANAGEMENT CLINIC

NPI Number: 1588568505
Health Care Provider/Practitioner: LONGEVITY WEIGHT MANAGEMENT CLINIC

Information about “1588568505” NPI (LONGEVITY WEIGHT MANAGEMENT CLINIC) exists in 1588568505 in HTML format HTML  |  1588568505 in plain Text format TXT  |  1588568505 in PDF (Portable Document Format) PDF  |  1588568505 in an XML format XML  formats.

NPI Number : 1588568505 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1588568505",
    "EntityType": "Organization",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": null,
    "IsOrgSubpart": "N",
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": "LONGEVITY WEIGHT MANAGEMENT CLINIC",
    "LastName": null,
    "FirstName": null,
    "MiddleName": null,
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": null,
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": "6",
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "16526 W 78TH ST STE 188",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "EDEN PRAIRIE",
    "MailingAddressStateName": "MN",
    "MailingAddressPostalCode": "55346-4302",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "612-327-2228",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "16273 BAYWOOD LANE",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "EDEN PRAIRIE",
    "PracticeLocationAddressStateName": "MN",
    "PracticeLocationAddressPostalCode": "55346-4302",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "612-327-2228",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "10/05/2026",
    "LastUpdateDate": "10/05/2026",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": null,
    "Gender": null,
    "AuthorizedOfficialLastName": "IKEMAN",
    "AuthorizedOfficialFirstName": "NATALIE",
    "AuthorizedOfficialMiddleName": "LOUISE",
    "AuthorizedOfficialTitle": "CEO",
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": "PA-C",
    "AuthorizedOfficialTelephoneNumber": "612-327-2228",
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "207QB0002X",
        "TaxonomyName": "Obesity Medicine (Family Medicine) Physician",
        "LicenseNumber": null,
        "LicenseNumberStateCode": "NULL",
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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