Provider Demographics
NPI:1093461048
Name:LAKE MINNETONKA MOBILE WELLNESS, PA
Entity Type:Organization
Organization Name:LAKE MINNETONKA MOBILE WELLNESS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:STRANDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:952-222-7886
Mailing Address - Street 1:14604 WOODHAVEN RD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-2362
Mailing Address - Country:US
Mailing Address - Phone:952-222-7886
Mailing Address - Fax:
Practice Address - Street 1:14604 WOODHAVEN RD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345-2362
Practice Address - Country:US
Practice Address - Phone:952-222-7886
Practice Address - Fax:612-235-7918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-28
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty