Provider Demographics
NPI:1972860526
Name:LIFETREE CLINIC
Entity Type:Organization
Organization Name:LIFETREE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KYU HONG
Authorized Official - Middle Name:
Authorized Official - Last Name:TAE
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:612-723-2042
Mailing Address - Street 1:14585 GRAND AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55306-5719
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14585 GRAND AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306-5719
Practice Address - Country:US
Practice Address - Phone:952-435-7349
Practice Address - Fax:952-417-6159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-20
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1529171100000X
MN0082364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult HealthGroup - Multi-Specialty