Provider Demographics
NPI:1912302845
Name:MIND BODY WELLNESS LLC
Entity Type:Organization
Organization Name:MIND BODY WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:BAHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLESTAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-345-5420
Mailing Address - Street 1:1753 E BROADWAY RD STE 101-460
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-2081
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1753 E BROADWAY RD STE 101-460
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-2081
Practice Address - Country:US
Practice Address - Phone:480-345-5420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ422142084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty