Provider Demographics
NPI:1033284146
Name:SELS SENIOR EXERCISE LIFESTYLE SERVICES
Entity Type:Organization
Organization Name:SELS SENIOR EXERCISE LIFESTYLE SERVICES
Other - Org Name:SELS INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SWAMI
Authorized Official - Suffix:
Authorized Official - Credentials:CES
Authorized Official - Phone:651-208-4564
Mailing Address - Street 1:1044 CENTERVILLE CIR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:VADNAIS HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55127-6346
Mailing Address - Country:US
Mailing Address - Phone:651-774-2107
Mailing Address - Fax:651-774-1098
Practice Address - Street 1:5950 CHURCHILL ST
Practice Address - Street 2:
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-8427
Practice Address - Country:US
Practice Address - Phone:651-208-4564
Practice Address - Fax:651-774-2107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNC10380302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN764117600OtherMHCP