=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316536048
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINDFUL MOVEMENT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2021
-----------------------------------------------------
Last Update Date | 01/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 85 REGENT AVE
-----------------------------------------------------
City | BLUFFTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29910-8839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-586-5123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 85 REGENT AVE
-----------------------------------------------------
City | BLUFFTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29910-8839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-586-5123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MEGHAN KLUNK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 717-586-5123
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------