Healthcare Provider Details

I. General information

NPI: 1932825783
Provider Name (Legal Business Name): MINDSET WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2022
Last Update Date: 04/12/2025
Certification Date: 04/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1309 COFFEEN AVE STE 1200
SHERIDAN WY
82801-5777
US

IV. Provider business mailing address

5465 HIGHWAY 42 UNIT 246
ELLENWOOD GA
30294-4042
US

V. Phone/Fax

Practice location:
  • Phone: 470-988-2639
  • Fax:
Mailing address:
  • Phone: 470-646-3738
  • Fax: 888-910-6463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. OMOLOLA OTUBAGA
Title or Position: OWNER
Credential:
Phone: 470-988-2639