Healthcare Provider Details

I. General information

NPI: 1790304616
Provider Name (Legal Business Name): MIND BRIDGE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2020
Last Update Date: 04/10/2020
Certification Date: 04/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1390 CHAIN BRIDGE RD # 10033
MC LEAN VA
22101-3904
US

IV. Provider business mailing address

1390 CHAIN BRIDGE RD # 10033
MC LEAN VA
22101-3904
US

V. Phone/Fax

Practice location:
  • Phone: 571-766-8107
  • Fax:
Mailing address:
  • Phone: 571-766-8107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KURWA NYIGU
Title or Position: CEO
Credential: MD
Phone: 336-624-7164