Provider Demographics
NPI:1598330219
Name:MINNESOTA VITALITY AND ANTI-AGING CENTER
Entity Type:Organization
Organization Name:MINNESOTA VITALITY AND ANTI-AGING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSHIP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-245-2454
Mailing Address - Street 1:520 HIGHWAY 96 W STE 200
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-1963
Mailing Address - Country:US
Mailing Address - Phone:651-374-4014
Mailing Address - Fax:651-374-4019
Practice Address - Street 1:520 HIGHWAY 96 W STE 200
Practice Address - Street 2:
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-1963
Practice Address - Country:US
Practice Address - Phone:651-374-4014
Practice Address - Fax:651-374-4019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-25
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty