Healthcare Provider Details

I. General information

NPI: 1548069859
Provider Name (Legal Business Name): MIND BODY OPTIMIZATION ONLINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2025
Last Update Date: 01/21/2026
Certification Date: 01/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5405 W 151ST ST
LEAWOOD KS
66224-8700
US

IV. Provider business mailing address

16 VILLAGE LN STE 200
COLLEYVILLE TX
76034-2948
US

V. Phone/Fax

Practice location:
  • Phone: 682-900-6631
  • Fax: 800-416-8145
Mailing address:
  • Phone: 682-900-6631
  • Fax: 800-416-8145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID J MORAINE
Title or Position: LEGAL COUNSEL
Credential: ESQ
Phone: 469-990-3626