Provider Demographics
NPI:1538477013
Name:MIND BODY SPIRIT LLC
Entity Type:Organization
Organization Name:MIND BODY SPIRIT LLC
Other - Org Name:MIND BODY SPIRIT - A HOLISTIC COMMUNITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:E
Authorized Official - Last Name:DARE
Authorized Official - Suffix:
Authorized Official - Credentials:LMP, LMT
Authorized Official - Phone:503-893-4022
Mailing Address - Street 1:2705 E BURNSIDE ST STE 104
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1767
Mailing Address - Country:US
Mailing Address - Phone:503-893-4022
Mailing Address - Fax:
Practice Address - Street 1:2705 E BURNSIDE ST STE 104
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1767
Practice Address - Country:US
Practice Address - Phone:503-893-4022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-19
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60040619225700000X, 225700000X
OR17071225700000X, 225700000X
WAMA60138699225700000X
OR17390225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty