Provider Demographics
NPI:1740222496
Name:LIFE MEDICAL, P.A.
Entity Type:Organization
Organization Name:LIFE MEDICAL, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL CONTROLLER
Authorized Official - Prefix:MS
Authorized Official - First Name:OLGA
Authorized Official - Middle Name:V
Authorized Official - Last Name:SHEVELEVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-933-1121
Mailing Address - Street 1:4201 EXCELSIOR BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4728
Mailing Address - Country:US
Mailing Address - Phone:952-933-8900
Mailing Address - Fax:952-945-9536
Practice Address - Street 1:4201 EXCELSIOR BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-4728
Practice Address - Country:US
Practice Address - Phone:952-933-1121
Practice Address - Fax:952-945-9536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN=========OtherTAX ID