Provider Demographics
NPI:1104007756
Name:MIND BODY SPIRIT CARE CLINIC INC
Entity Type:Organization
Organization Name:MIND BODY SPIRIT CARE CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT-OWNER/PROVIDER
Authorized Official - Prefix:MS
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:DEANNE
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-BC
Authorized Official - Phone:618-624-2788
Mailing Address - Street 1:215 N BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881-1511
Mailing Address - Country:US
Mailing Address - Phone:618-960-8796
Mailing Address - Fax:
Practice Address - Street 1:9640 MALLARD DR
Practice Address - Street 2:
Practice Address - City:MASCOUTAH
Practice Address - State:IL
Practice Address - Zip Code:62258-2762
Practice Address - Country:US
Practice Address - Phone:618-960-8796
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-23
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty