=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346837812
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BALANCED MIND INTEGRATIVE CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2020
-----------------------------------------------------
Last Update Date | 07/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3440 HOLLYWOOD BLVD STE 415
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33021-6933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-367-2313
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3440 HOLLYWOOD BLVD STE 415
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33021-6933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-295-7116
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER OF ENTITY
-----------------------------------------------------
Name | SARA GENA ISRAEL
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 954-295-7116
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------