Provider Demographics
NPI:1780935411
Name:MINDFUL PHYSICAL THERAPY
Entity type:Organization
Organization Name:MINDFUL PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:BORGESON
Authorized Official - Suffix:
Authorized Official - Credentials:MPT, MS
Authorized Official - Phone:415-256-9990
Mailing Address - Street 1:901 SIR FRANCIS DRAKE BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:KENTFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94904-1502
Mailing Address - Country:US
Mailing Address - Phone:415-256-9990
Mailing Address - Fax:415-256-9991
Practice Address - Street 1:901 SIR FRANCIS DRAKE BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:KENTFIELD
Practice Address - State:CA
Practice Address - Zip Code:94904-1502
Practice Address - Country:US
Practice Address - Phone:415-256-9990
Practice Address - Fax:415-256-9991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-20
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT24068261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC3455707OtherCALIFORNIA CORPORATION NUMBER/S-CORP ENTITY ID