Healthcare Provider Details

I. General information

NPI: 1780348508
Provider Name (Legal Business Name): BODY & MIND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2021
Last Update Date: 05/09/2023
Certification Date: 05/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 POLK ST STE F
TWIN FALLS ID
83301-4864
US

IV. Provider business mailing address

475 POLK ST STE F
TWIN FALLS ID
83301-4864
US

V. Phone/Fax

Practice location:
  • Phone: 208-751-9708
  • Fax: 208-736-0890
Mailing address:
  • Phone: 208-751-9708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LESLIE HASS
Title or Position: OWNER
Credential: NP
Phone: 208-751-9708