Provider Demographics
NPI:1740090026
Name:MIND BODY NOURISH LLC
Entity type:Organization
Organization Name:MIND BODY NOURISH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANISA
Authorized Official - Middle Name:
Authorized Official - Last Name:ORTIZ
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:305-930-2967
Mailing Address - Street 1:2901 MEREDITH PL
Mailing Address - Street 2:
Mailing Address - City:BENSALEM
Mailing Address - State:PA
Mailing Address - Zip Code:19020-2258
Mailing Address - Country:US
Mailing Address - Phone:267-455-9230
Mailing Address - Fax:
Practice Address - Street 1:2625 W GIRARD AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19130-1333
Practice Address - Country:US
Practice Address - Phone:305-930-2967
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-09
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty