=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164281002
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINDBALANCED, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2024
-----------------------------------------------------
Last Update Date | 03/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1545 JEFFERSON AVE APT 102
-----------------------------------------------------
City | MIAMI BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33139-3509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-714-4811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1601-1 N MAIN ST UNIT 3159
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32206-7707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-714-4811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JOSH HILL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-714-4811
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084B0040X
-----------------------------------------------------
Taxonomy Name | Behavioral Neurology & Neuropsychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------