Provider Demographics
NPI:1275770752
Name:MIND & BODY WORKS, INC.
Entity Type:Organization
Organization Name:MIND & BODY WORKS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ERICH
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-923-7684
Mailing Address - Street 1:3340 WAUKE ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96815-4452
Mailing Address - Country:US
Mailing Address - Phone:808-923-7684
Mailing Address - Fax:866-452-8214
Practice Address - Street 1:3340 WAUKE ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96815-4452
Practice Address - Country:US
Practice Address - Phone:808-923-7684
Practice Address - Fax:866-452-8214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-20
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIHI633171100000X
HIMD11262208000000X, 2080P0006X, 2084P0800X, 2084P0804X, 261Q00000X
2255A2300X, 226300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty
No226300000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersKinesiotherapistGroup - Multi-Specialty