Provider Demographics
NPI:1295420651
Name:MIND AND BODY RESTORED
Entity type:Organization
Organization Name:MIND AND BODY RESTORED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP
Authorized Official - Prefix:
Authorized Official - First Name:JANA
Authorized Official - Middle Name:
Authorized Official - Last Name:QUALL
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:208-957-7808
Mailing Address - Street 1:3117 W AUGUSTIN DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-5362
Mailing Address - Country:US
Mailing Address - Phone:208-957-7808
Mailing Address - Fax:949-695-2456
Practice Address - Street 1:913 W CANFIELD AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-9764
Practice Address - Country:US
Practice Address - Phone:208-957-7808
Practice Address - Fax:949-695-2456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-10
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty