Provider Demographics
NPI:1841865656
Name:MIND SPA LLC
Entity type:Organization
Organization Name:MIND SPA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BUSINESS DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:509-385-4800
Mailing Address - Street 1:3295 BLAKE ST APT 205
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80205-2469
Mailing Address - Country:US
Mailing Address - Phone:509-385-4800
Mailing Address - Fax:
Practice Address - Street 1:6303 E DAKOTA AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80224-1246
Practice Address - Country:US
Practice Address - Phone:413-205-8665
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-24
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)