Provider Demographics
NPI:1598443723
Name:LIFEWAY HEALTH & WELLNESS LLC
Entity Type:Organization
Organization Name:LIFEWAY HEALTH & WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODARD
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:763-438-3814
Mailing Address - Street 1:3720 152ND LN NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-3010
Mailing Address - Country:US
Mailing Address - Phone:763-438-3814
Mailing Address - Fax:
Practice Address - Street 1:6964 SYCAMORE CT N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369
Practice Address - Country:US
Practice Address - Phone:763-438-3814
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-07
Last Update Date:2023-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care