Healthcare Provider Details

I. General information

NPI: 1316673163
Provider Name (Legal Business Name): MIND & MANE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2022
Last Update Date: 07/25/2022
Certification Date: 07/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3664 GENESIS LN
WAKE FOREST NC
27587-6088
US

IV. Provider business mailing address

3664 GENESIS LN
WAKE FOREST NC
27587-6088
US

V. Phone/Fax

Practice location:
  • Phone: 443-538-7275
  • Fax:
Mailing address:
  • Phone: 443-538-7275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. ZEAN KING
Title or Position: CEO
Credential:
Phone: 443-949-6710