MEDICARE: MINDS N MOTION, 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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1497512610
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDS N MOTION, LLC

Provider Business Mailing Address
First Line	:	3613 FLEETWOOD DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-2377
Country	:	US
Telephone Number	:	817-996-0402
Fax Number	:	682-628-0891

Provider Business Practice Location Address
First Line	:	3613 FLEETWOOD DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-2377
Country	:	US
Telephone Number	:	817-996-0402
Fax Number	:	682-628-0891

Authorized Official
Title or Position	:	OWNER
Name	:	YASMIN MICHELLE JACKSON
Credential	:
Telephone Number	:	817-996-0402

Provider Enumeration Date	:	03/04/2024
Last Update Date	:	03/04/2024

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Directions to “MINDS N MOTION, LLC ” Practice Location

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