Provider Demographics
NPI:1780960229
Name:MIND, BODY, SOUL
Entity type:Organization
Organization Name:MIND, BODY, SOUL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:BRITT
Authorized Official - Last Name:MICHAELS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:907-696-3657
Mailing Address - Street 1:PO BOX 770502
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-0502
Mailing Address - Country:US
Mailing Address - Phone:907-696-3657
Mailing Address - Fax:907-622-3657
Practice Address - Street 1:12103B HORSESHOE DR
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7547
Practice Address - Country:US
Practice Address - Phone:907-696-3657
Practice Address - Fax:907-622-3657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-28
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1653225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty