Healthcare Provider Details

I. General information

NPI: 1598308504
Provider Name (Legal Business Name): BODY & MIND WORKS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2019
Last Update Date: 10/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 N STATE ROAD 7
LAUDERHILL FL
33313-5853
US

IV. Provider business mailing address

1600 N STATE ROAD 7
LAUDERHILL FL
33313-5853
US

V. Phone/Fax

Practice location:
  • Phone: 954-554-3454
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JONELLE RIVAS-GIBSON
Title or Position: NURSE PRACTITIONER
Credential:
Phone: 954-900-9804