MEDICARE: BODY & MIND UPLIFMENT LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1154934131
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BODY & MIND UPLIFMENT LLC

Provider Business Mailing Address
First Line	:	2215 RENAISSANCE DR STE A
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-6723
Country	:	US
Telephone Number	:	702-340-9350
Fax Number	:

Provider Business Practice Location Address
First Line	:	2215 RENAISSANCE DR STE A
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-6723
Country	:	US
Telephone Number	:	702-488-4918
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PROVIDER
Name	:	ROSALITA JURANI
Credential	:	MD
Telephone Number	:	702-340-9350

Provider Enumeration Date	:	08/28/2020
Last Update Date	:	08/28/2020

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