Provider Demographics
NPI:1134777402
Name:MIND & BODY AT HOME LIVING SERVICES
Entity type:Organization
Organization Name:MIND & BODY AT HOME LIVING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:MYSTI
Authorized Official - Middle Name:NICHELE
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:757-774-3360
Mailing Address - Street 1:8406 SHEPHERDS WATCH DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-7871
Mailing Address - Country:US
Mailing Address - Phone:757-774-3360
Mailing Address - Fax:
Practice Address - Street 1:8406 SHEPHERDS WATCH DR
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23832-7871
Practice Address - Country:US
Practice Address - Phone:757-774-3360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-29
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty