Healthcare Provider Details

I. General information

NPI: 1912693912
Provider Name (Legal Business Name): MINDFUL MEDICINE COUNSELING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2023
Last Update Date: 11/11/2023
Certification Date: 11/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10365 HOOD RD S STE 204
JACKSONVILLE FL
32257-3261
US

IV. Provider business mailing address

3914 DYLAN CT
JACKSONVILLE FL
32223-2707
US

V. Phone/Fax

Practice location:
  • Phone: 217-480-7298
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROMAN CRIOLLO
Title or Position: COO
Credential: MD
Phone: 217-480-7298