Provider Demographics
NPI:1609255363
Name:MINDFUL MEDICINE, PLLC
Entity Type:Organization
Organization Name:MINDFUL MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBORA
Authorized Official - Middle Name:G
Authorized Official - Last Name:TALLIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-687-6070
Mailing Address - Street 1:2134 NICHOLASVILLE RD
Mailing Address - Street 2:SUITE 12
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-2521
Mailing Address - Country:US
Mailing Address - Phone:859-687-6070
Mailing Address - Fax:859-687-6071
Practice Address - Street 1:2134 NICHOLASVILLE RD
Practice Address - Street 2:SUITE 12
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-2521
Practice Address - Country:US
Practice Address - Phone:859-687-6070
Practice Address - Fax:859-687-6071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-27
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39006208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty