Provider Demographics
NPI:1013261551
Name:MIND BODY WELLNESS CENTER
Entity Type:Organization
Organization Name:MIND BODY WELLNESS CENTER
Other - Org Name:MIND BODY ACUPUNCTURE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GHIM
Authorized Official - Middle Name:M
Authorized Official - Last Name:LAM
Authorized Official - Suffix:
Authorized Official - Credentials:DAOM
Authorized Official - Phone:818-500-1425
Mailing Address - Street 1:336 N CENTRAL AVE
Mailing Address - Street 2:# 3
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-3123
Mailing Address - Country:US
Mailing Address - Phone:818-500-1425
Mailing Address - Fax:818-500-8588
Practice Address - Street 1:420 S BEVERLY DR
Practice Address - Street 2:#100-17
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212-4426
Practice Address - Country:US
Practice Address - Phone:310-467-6436
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIND BODY WELLNESS CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-06
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA10207305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization