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General NPI Number Information
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NPI Number | 1033914924
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Entity Type | Organization
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Legal Business Name | MINDFUL GLOW
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Dates
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Enumeration Date | 02/15/2025
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Last Update Date | 04/11/2025
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Provider Practice Location Address
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Address Line | 18111 BROOKHURST ST STE 5400
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City | FOUNTAIN VALLEY
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State | CA
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Zip | 92708-6728
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Country | US
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Telephone | 949-436-4666
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Fax |
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Provider Business Mailing Address
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Address Line | 18111 BROOKHURST ST STE 5400
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City | FOUNTAIN VALLEY
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State | CA
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Zip | 92708-6728
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | TAM DO
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Credential | PMHNP, FNP
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Telephone | 949-436-4666
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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