=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821910134
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH STAR METABOLIC AND PERFORMANCE CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2026
-----------------------------------------------------
Last Update Date | 07/28/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7300 FRANCE AVE S STE 301
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55435-4505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-800-3363
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16960 VALLEY RD
-----------------------------------------------------
City | EDEN PRAIRIE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55347-2833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-703-3935
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN/FOUNDER
-----------------------------------------------------
Name | TIMOTHY LOUIS ROACH
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 661-703-3935
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------