Provider Demographics
NPI:1891348546
Name:MIND ABOVE MATTER LLC
Entity Type:Organization
Organization Name:MIND ABOVE MATTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOLINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-447-3001
Mailing Address - Street 1:PO BOX 1058
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76097-1058
Mailing Address - Country:US
Mailing Address - Phone:817-447-3001
Mailing Address - Fax:
Practice Address - Street 1:1101 NASHVILLE AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76105-1530
Practice Address - Country:US
Practice Address - Phone:817-447-3001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIND ABOVE MATTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)