Provider Demographics
NPI:1740689694
Name:MIND & BODY TREATMENT AND RESEARCH INSTITUTE, PC
Entity type:Organization
Organization Name:MIND & BODY TREATMENT AND RESEARCH INSTITUTE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAJAGOPAL
Authorized Official - Middle Name:KEERTHY
Authorized Official - Last Name:SUNDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-685-2022
Mailing Address - Street 1:3060 EL CERRITO PLZ
Mailing Address - Street 2:SUITE 266
Mailing Address - City:EL CERRITO
Mailing Address - State:CA
Mailing Address - Zip Code:94530-4011
Mailing Address - Country:US
Mailing Address - Phone:510-685-2022
Mailing Address - Fax:
Practice Address - Street 1:5700 DIVISION ST
Practice Address - Street 2:200
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-3257
Practice Address - Country:US
Practice Address - Phone:951-300-4905
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-16
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA942232084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101426267 0001Medicaid
PA101426267 0001Medicaid