Provider Demographics
NPI:1770122277
Name:MIND & BODY HEALTHCARE LLC
Entity type:Organization
Organization Name:MIND & BODY HEALTHCARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:E
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:575-489-4750
Mailing Address - Street 1:714 GARDEN PL
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-7767
Mailing Address - Country:US
Mailing Address - Phone:575-489-4750
Mailing Address - Fax:575-586-4414
Practice Address - Street 1:1700 N UNION AVE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-3267
Practice Address - Country:US
Practice Address - Phone:575-489-4750
Practice Address - Fax:575-586-4414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-31
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care