Healthcare Provider Details

I. General information

NPI: 1831544832
Provider Name (Legal Business Name): MINDFUL INTEGRATED MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2016
Last Update Date: 10/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 E OAK ST
KISSIMMEE FL
34744-4573
US

IV. Provider business mailing address

719 E OAK ST
KISSIMMEE FL
34744-4580
US

V. Phone/Fax

Practice location:
  • Phone: 407-846-0533
  • Fax: 407-518-1730
Mailing address:
  • Phone: 407-846-0533
  • Fax: 407-518-1730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. IVETTE A CHARNECO
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 407-846-0533