Healthcare Provider Details

I. General information

NPI: 1205541976
Provider Name (Legal Business Name): IN MIND & BODY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2023
Last Update Date: 01/17/2023
Certification Date: 01/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

337 W 806 N
VALPARAISO IN
46385-7973
US

IV. Provider business mailing address

337 W 806 N
VALPARAISO IN
46385-7973
US

V. Phone/Fax

Practice location:
  • Phone: 773-520-1950
  • Fax:
Mailing address:
  • Phone: 773-520-1950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: BRYAN WALDO
Title or Position: OWNER
Credential:
Phone: 773-520-1950