Provider Demographics
NPI:1205455961
Name:CHANGING MINDS MEDICINE LLC
Entity type:Organization
Organization Name:CHANGING MINDS MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-405-8088
Mailing Address - Street 1:PO BOX 752003
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89136-2003
Mailing Address - Country:US
Mailing Address - Phone:702-405-8088
Mailing Address - Fax:702-405-6066
Practice Address - Street 1:2960 W HORIZON RIDGE PKWY
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4666
Practice Address - Country:US
Practice Address - Phone:702-405-8088
Practice Address - Fax:702-405-6066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-13
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty