Provider Demographics
NPI:1124554076
Name:MIND BODY SOUL MEDICAL SPA
Entity Type:Organization
Organization Name:MIND BODY SOUL MEDICAL SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANOUSH
Authorized Official - Middle Name:
Authorized Official - Last Name:KETSOYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:818-522-3555
Mailing Address - Street 1:2415 LOS AMIGOS ST
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214-3032
Mailing Address - Country:US
Mailing Address - Phone:818-522-3555
Mailing Address - Fax:
Practice Address - Street 1:2415 LOS AMIGOS ST
Practice Address - Street 2:
Practice Address - City:LA CRESCENTA
Practice Address - State:CA
Practice Address - Zip Code:91214-3032
Practice Address - Country:US
Practice Address - Phone:818-522-3555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ARAA ENTERPRISE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health