Healthcare Provider Details

I. General information

NPI: 1245068626
Provider Name (Legal Business Name): MINDFUL MOBILE MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2024
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

623 E FORT UNION BLVD STE 105
MIDVALE UT
84047-5529
US

IV. Provider business mailing address

623 E FORT UNION BLVD STE 105
MIDVALE UT
84047-5529
US

V. Phone/Fax

Practice location:
  • Phone: 801-879-2664
  • Fax:
Mailing address:
  • Phone: 385-412-1660
  • Fax: 801-261-5856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TYLER YOUNG
Title or Position: VP
Credential:
Phone: 801-879-2664