Healthcare Provider Details

I. General information

NPI: 1497273916
Provider Name (Legal Business Name): MIND BODY SPORT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2017
Last Update Date: 04/20/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 S ONEIDA ST STE 600
DENVER CO
80224-2555
US

IV. Provider business mailing address

2121 S ONEIDA ST STE 600
DENVER CO
80224-2555
US

V. Phone/Fax

Practice location:
  • Phone: 720-863-6100
  • Fax:
Mailing address:
  • Phone: 720-863-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: IAN J PALOMBO
Title or Position: PRESIDENT
Credential: LPC
Phone: 720-863-6100