Healthcare Provider Details

I. General information

NPI: 1487469961
Provider Name (Legal Business Name): MIND BODY SOUL REVIVAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2025
Last Update Date: 02/11/2025
Certification Date: 02/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 VANCE ST
LAKEWOOD CO
80214-4828
US

IV. Provider business mailing address

845 VANCE ST
LAKEWOOD CO
80214-4828
US

V. Phone/Fax

Practice location:
  • Phone: 774-270-7018
  • Fax:
Mailing address:
  • Phone: 774-270-7018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name: EMMA O'CONNOR
Title or Position: REGISTERED DIETITIAN
Credential: MS, RD, CEDS
Phone: 774-270-7018