Provider Demographics
NPI:1932522745
Name:MIND BODY AND SPORTS CONNECTION
Entity Type:Organization
Organization Name:MIND BODY AND SPORTS CONNECTION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DION
Authorized Official - Middle Name:A
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-764-8878
Mailing Address - Street 1:3035 LINDELL RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-6818
Mailing Address - Country:US
Mailing Address - Phone:702-764-8878
Mailing Address - Fax:
Practice Address - Street 1:3035 LINDELL RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-6818
Practice Address - Country:US
Practice Address - Phone:702-764-8878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAS VEGAS SHOWGIRLZ LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-01-30
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5636-C251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health