Provider Demographics
NPI:1396282794
Name:LIFESTREAM WELLNESS, LLC
Entity type:Organization
Organization Name:LIFESTREAM WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, LICENSED ACUPUNCTURIST
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKER-MCLAUGHLIN
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:651-338-3574
Mailing Address - Street 1:240 SPRING ST UNIT 408
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-4704
Mailing Address - Country:US
Mailing Address - Phone:651-338-3574
Mailing Address - Fax:
Practice Address - Street 1:3440 FEDERAL DR
Practice Address - Street 2:SUITE 140
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-3501
Practice Address - Country:US
Practice Address - Phone:651-338-3574
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-23
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1772261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center