Healthcare Provider Details

I. General information

NPI: 1932634144
Provider Name (Legal Business Name): MIND AND BODY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2017
Last Update Date: 04/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

I CENTRO INTERNACIONAL DE MERCADEO SUITE 311
GUAYNABO PR
00969
US

IV. Provider business mailing address

576 AVE ARTERIAL B COLISEUM TOWER APT 2109
SAN JUAN PR
00918
US

V. Phone/Fax

Practice location:
  • Phone: 787-224-9188
  • Fax: 939-437-4302
Mailing address:
  • Phone: 787-642-6816
  • Fax: 939-437-4302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number18775
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number18775
License Number StatePR

VIII. Authorized Official

Name: DR. VERONICA MIRANDA LOPEZ
Title or Position: PSYCHIATRY
Credential: M.D.
Phone: 787-642-6816