1164804977 NPI number — BODY MIND SPIRIT THERAPY CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164804977 NPI number — BODY MIND SPIRIT THERAPY CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BODY MIND SPIRIT THERAPY CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164804977
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/29/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1045 EAST ATLANTIC AVENUE
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
DELRAY BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33483
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-727-6858
Provider Business Mailing Address Fax Number:
561-330-4264

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1045 EAST ATLANTIC AVENUE
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
DELRAY BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33483
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-727-6858
Provider Business Practice Location Address Fax Number:
561-330-4264
Provider Enumeration Date:
06/29/2015

Additional Information

Authorized Official

Authorized Official Last Name:
PINEDA
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
PIERCE
Authorized Official Title or Position:
PRESIDENT/DIRECTOR
Authorized Official Telephone Number:
561-727-6858

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  MT1988 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 766173800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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