Provider Demographics
NPI:1073272167
Name:MIND & BODY HEALTH CLINIC
Entity Type:Organization
Organization Name:MIND & BODY HEALTH CLINIC
Other - Org Name:MIND & BODY HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:REID
Authorized Official - Last Name:BEECHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-993-7432
Mailing Address - Street 1:901 DOVER DR STE 214
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-5500
Mailing Address - Country:US
Mailing Address - Phone:407-476-2005
Mailing Address - Fax:949-612-7427
Practice Address - Street 1:901 DOVER DR STE 214
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-5500
Practice Address - Country:US
Practice Address - Phone:407-476-2005
Practice Address - Fax:949-612-7427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-16
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
BT30077324OtherCA STATE LICENSE NUMBER