Provider Demographics
NPI:1548564073
Name:MIND BODY HEALTHLINK
Entity Type:Organization
Organization Name:MIND BODY HEALTHLINK
Other - Org Name:CARL FULWILER, M.D., PH.D.
Other - Org Type:Other Name
Authorized Official - Title/Position:PRINCIPAL OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:FULWILER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-271-3342
Mailing Address - Street 1:26 CASTLE RD
Mailing Address - Street 2:
Mailing Address - City:NORTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01532-1249
Mailing Address - Country:US
Mailing Address - Phone:617-271-3342
Mailing Address - Fax:
Practice Address - Street 1:26 CASTLE RD
Practice Address - Street 2:
Practice Address - City:NORTHBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01532-1249
Practice Address - Country:US
Practice Address - Phone:617-271-3342
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-23
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA80208261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty