Healthcare Provider Details

I. General information

NPI: 1699155457
Provider Name (Legal Business Name): OPEN MIND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2015
Last Update Date: 06/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5920 N GOVERNMENT WAY #4
DALTON GARDENS ID
83815-9200
US

IV. Provider business mailing address

5920 N GOVERNMENT WAY #4
DALTON GARDENS ID
83815-9200
US

V. Phone/Fax

Practice location:
  • Phone: 208-819-0550
  • Fax:
Mailing address:
  • Phone: 208-819-0550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberLPC-5123
License Number StateID

VIII. Authorized Official

Name: MICHAEL DANIEL GARCIA
Title or Position: OWNER
Credential: LPC
Phone: 208-819-0550