Healthcare Provider Details

I. General information

NPI: 1467115766
Provider Name (Legal Business Name): MINDFUL LIVING CENTER NY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2021
Last Update Date: 01/06/2022
Certification Date: 01/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3670 S BENZING RD
ORCHARD PARK NY
14127-1737
US

IV. Provider business mailing address

900 PACIFIC COAST HWY APT 105
HUNTINGTON BEACH CA
92648-4859
US

V. Phone/Fax

Practice location:
  • Phone: 949-409-5660
  • Fax:
Mailing address:
  • Phone: 323-580-9477
  • 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: ERIK TOLONEN
Title or Position: VP
Credential:
Phone: 323-580-9477