=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366242273
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINDFUL MED MANAGEMENT INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2025
-----------------------------------------------------
Last Update Date | 04/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 MARINERS WAY
-----------------------------------------------------
City | PORT JEFFERSON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11777-1848
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-991-0052
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 MARINERS WAY
-----------------------------------------------------
City | PORT JEFFERSON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11777-1848
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-509-7488
-----------------------------------------------------
Fax | 631-778-8004
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | APRIL LEE
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 631-509-7488
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QI0500X
-----------------------------------------------------
Taxonomy Name | Infusion Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------