Healthcare Provider Details

I. General information

NPI: 1467004812
Provider Name (Legal Business Name): THE PEACEFUL MIND FACTORY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2019
Last Update Date: 07/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3408 W 84TH ST STE 305
HIALEAH FL
33018-4943
US

IV. Provider business mailing address

1165 NW 184TH WAY
PEMBROKE PINES FL
33029-3633
US

V. Phone/Fax

Practice location:
  • Phone: 786-663-3983
  • Fax: 786-803-8838
Mailing address:
  • Phone: 786-663-3983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: ANA MARIA LOPEZ MEDRANO
Title or Position: OWNER
Credential:
Phone: 786-663-3983