Provider Demographics
NPI:1972074839
Name:MINDFUL PERFORMANCE CENTER LIMITED LIABILITY COMPANY
Entity Type:Organization
Organization Name:MINDFUL PERFORMANCE CENTER LIMITED LIABILITY COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:WARREN
Authorized Official - Last Name:VIOLAND
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:443-538-5758
Mailing Address - Street 1:13380 CLARKSVILLE PIKE STE I
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:MD
Mailing Address - Zip Code:20777-9725
Mailing Address - Country:US
Mailing Address - Phone:443-538-5758
Mailing Address - Fax:
Practice Address - Street 1:6570 DOBBIN RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-5855
Practice Address - Country:US
Practice Address - Phone:443-538-5758
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-17
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports MedicineGroup - Single Specialty