Provider Demographics
NPI:1265465934
Name:LIFETIME WELLNESS CENTER, P.A.
Entity type:Organization
Organization Name:LIFETIME WELLNESS CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:C
Authorized Official - Last Name:PLOESSL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-559-5627
Mailing Address - Street 1:14215 44TH PL N
Mailing Address - Street 2:#6
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446-2344
Mailing Address - Country:US
Mailing Address - Phone:763-559-5627
Mailing Address - Fax:763-559-5627
Practice Address - Street 1:14215 44TH PL N
Practice Address - Street 2:#6
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55446-2344
Practice Address - Country:US
Practice Address - Phone:763-559-5627
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4505111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN294M7LIMedicare UPIN