Healthcare Provider Details

I. General information

NPI: 1154948180
Provider Name (Legal Business Name): MINDOULA HEALTH INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2020
Last Update Date: 01/11/2024
Certification Date: 01/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

232 CAPITOL ST
CHARLESTON WV
25301-2234
US

IV. Provider business mailing address

8040 GEORGIA AVE STE 170
SILVER SPRING MD
20910-4959
US

V. Phone/Fax

Practice location:
  • Phone: 888-879-9786
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: GREGORY COUTO
Title or Position: SVP OPERATIONS
Credential:
Phone: 954-650-2802