Healthcare Provider Details

I. General information

NPI: 1770122277
Provider Name (Legal Business Name): MIND & BODY HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2019
Last Update Date: 01/08/2020
Certification Date: 01/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 N UNION AVE
ROSWELL NM
88201-3267
US

IV. Provider business mailing address

714 GARDEN PL
ROSWELL NM
88201-7767
US

V. Phone/Fax

Practice location:
  • Phone: 575-489-4750
  • Fax: 575-586-4414
Mailing address:
  • Phone: 575-489-4750
  • Fax: 575-586-4414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JON E PERRY
Title or Position: OWNER
Credential: PA
Phone: 575-489-4750