Provider Demographics
NPI:1558801357
Name:TATTOO REMOVAL SHOP
Entity Type:Organization
Organization Name:TATTOO REMOVAL SHOP
Other - Org Name:LION THORN CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TOWEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-922-9462
Mailing Address - Street 1:7373 FRANCE AVE S
Mailing Address - Street 2:SUITE 504
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-4549
Mailing Address - Country:US
Mailing Address - Phone:952-922-9462
Mailing Address - Fax:952-922-8914
Practice Address - Street 1:7373 FRANCE AVE S
Practice Address - Street 2:SUITE 504
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4549
Practice Address - Country:US
Practice Address - Phone:952-922-9462
Practice Address - Fax:952-922-8914
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TATTOO REMOVAL SHOP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-28
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN32775207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN276000200Medicaid
MN276000200Medicaid