Provider Demographics
NPI:1164437828
Name:MIND BODY PHYSICAL THERAPY & WELLNESS CENTER, INC.
Entity Type:Organization
Organization Name:MIND BODY PHYSICAL THERAPY & WELLNESS CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:QUITASOL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:443-279-1777
Mailing Address - Street 1:1400 COPPERMINE TER
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-2012
Mailing Address - Country:US
Mailing Address - Phone:443-279-1777
Mailing Address - Fax:
Practice Address - Street 1:1400 COPPERMINE TER
Practice Address - Street 2:TERRACE
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-2012
Practice Address - Country:US
Practice Address - Phone:443-279-1777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1841228855Medicare UPIN
MD860LMedicare ID - Type UnspecifiedMEDICARE NUMBER
1316977127Medicare UPIN