Provider Demographics
NPI:1225340789
Name:MINDBODY INTEGRATED
Entity Type:Organization
Organization Name:MINDBODY INTEGRATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MAULIK
Authorized Official - Middle Name:
Authorized Official - Last Name:TRIVEDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-650-3239
Mailing Address - Street 1:809 E BLOOMINGDALE AVE
Mailing Address - Street 2:PMB # 377
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-8113
Mailing Address - Country:US
Mailing Address - Phone:813-650-3239
Mailing Address - Fax:813-464-2787
Practice Address - Street 1:2204 S PARSONS AVE
Practice Address - Street 2:
Practice Address - City:SEFFNER
Practice Address - State:FL
Practice Address - Zip Code:33584-5212
Practice Address - Country:US
Practice Address - Phone:813-684-3222
Practice Address - Fax:813-464-2787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-12
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 842082084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL265223400Medicaid
FL12012YMedicare PIN
FLH50599Medicare UPIN