Healthcare Provider Details

I. General information

NPI: 1508138561
Provider Name (Legal Business Name): MIND BODY SPIRIT WELLNESS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2012
Last Update Date: 02/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 BUFORD HWY NE STE T65
ATLANTA GA
30329-2145
US

IV. Provider business mailing address

2484 BRIARCLIFF RD NE STE 22-315
ATLANTA GA
30329-3011
US

V. Phone/Fax

Practice location:
  • Phone: 404-478-9868
  • Fax:
Mailing address:
  • Phone: 404-478-9868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number055194
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number055194
License Number StateGA

VIII. Authorized Official

Name: MAIYSHA TANIA CLAIRBORNE
Title or Position: PRESIDENT/CEO
Credential: MD
Phone: 404-478-9868