Provider Demographics
NPI:1720480395
Name:LIONS GYM INC
Entity Type:Organization
Organization Name:LIONS GYM INC
Other - Org Name:LIONS GYM AND WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:MENYA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-535-0700
Mailing Address - Street 1:4123 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-1808
Mailing Address - Country:US
Mailing Address - Phone:763-535-0700
Mailing Address - Fax:
Practice Address - Street 1:4123 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-1808
Practice Address - Country:US
Practice Address - Phone:763-535-0700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIONS GYM INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-09-25
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty