Provider Demographics
NPI:1003377995
Name:MIND&MOOD RESTORATION CLINIC LLC
Entity Type:Organization
Organization Name:MIND&MOOD RESTORATION CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-488-9604
Mailing Address - Street 1:521 E MITCHELL HAMMOCK RD STE 1101
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-8434
Mailing Address - Country:US
Mailing Address - Phone:407-488-9604
Mailing Address - Fax:321-300-1063
Practice Address - Street 1:521 E MITCHELL HAMMOCK RD STE 1101
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-8434
Practice Address - Country:US
Practice Address - Phone:407-488-9604
Practice Address - Fax:321-300-1063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty