Healthcare Provider Details

I. General information

NPI: 1639729932
Provider Name (Legal Business Name): PALO ALTO MIND BODY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2019
Last Update Date: 04/05/2023
Certification Date: 04/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 CALIFORNIA AVE
PALO ALTO CA
94306-1618
US

IV. Provider business mailing address

PO BOX 1011
PALO ALTO CA
94302-1011
US

V. Phone/Fax

Practice location:
  • Phone: 650-681-2900
  • Fax: 650-681-2646
Mailing address:
  • Phone: 650-681-2900
  • Fax: 650-681-2646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. M RAMEEN GHORIESHI
Title or Position: PHYSICIAN
Credential: MD, MPH
Phone: 650-681-2900