Provider Demographics
| NPI: | 1225045362 |
|---|---|
| Name: | LIFETRACK RESOURCES, INC. |
| Entity Type: | Organization |
| Organization Name: | LIFETRACK RESOURCES, INC. |
| Other - Org Name: | ST. PAUL REHABILITATION CENTER |
| Other - Org Type: | Former Legal Business Name |
| Authorized Official - Title/Position: | PRESIDENT |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | TRIXIE |
| Authorized Official - Middle Name: | ANN |
| Authorized Official - Last Name: | GOLBERG |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 651-227-8471 |
| Mailing Address - Street 1: | 709 UNIVERSITY AVE W |
| Mailing Address - Street 2: | |
| Mailing Address - City: | SAINT PAUL |
| Mailing Address - State: | MN |
| Mailing Address - Zip Code: | 55104-4804 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 651-227-8471 |
| Mailing Address - Fax: | 651-265-2318 |
| Practice Address - Street 1: | 709 UNIVERSITY AVE W |
| Practice Address - Street 2: | |
| Practice Address - City: | SAINT PAUL |
| Practice Address - State: | MN |
| Practice Address - Zip Code: | 55104-4804 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 651-227-8471 |
| Practice Address - Fax: | 651-265-2318 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-08-02 |
| Last Update Date: | 2013-05-30 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 103TC2200X | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | Group - Multi-Specialty |
| No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
| No | 224Z00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | Group - Multi-Specialty | |
| No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty | |
| No | 2251P0200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics | Group - Multi-Specialty |
| No | 225200000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | Group - Multi-Specialty | |
| No | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Group - Multi-Specialty | |
| No | 235Z00000X | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| MN | 1019353 | Other | PREFERRED ONE |
| MN | 119905 | Other | CHOICE PLUS |
| MN | 13112SP | Other | BCBS - OT |
| MN | 995555101 | Medicaid | |
| MN | 27779PA | Other | BCBS - PT |
| MN | 5900058 | Other | MEDICA DUAL SOLUTION |
| MN | 553476300 | Medicaid | |
| MN | 431M9LI | Other | BCBS - MENTAL HEALTH |
| MN | 995555100 | Medicaid | |
| MN | 102486 | Other | UCARE - PT/OT/SP |
| MN | 108931 | Other | UCARE - MENTAL HEALTH |
| MN | 505120046 | Other | MHP |
| MN | 28605PA | Other | BCBS - SP |
| MN | 6400054 | Other | MEDICA CROSS OVER MEDICAR |
| MN | 431M9LI | Other | BCBS - MENTAL HEALTH |
| MN | 431M9LI | Other | BCBS - MENTAL HEALTH |
