=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497252357
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINDFUL RECOVERY ADDICTION SPECIALIST, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2018
-----------------------------------------------------
Last Update Date | 07/03/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20463 ALBERTA ST
-----------------------------------------------------
City | ONEIDA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-286-3292
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20463 ALBERTA ST
-----------------------------------------------------
City | ONEIDA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37841-3509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-286-3292
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ENROLLMENT CONSULTANT
-----------------------------------------------------
Name | PAUL CAUDILL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-521-9097
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207QA0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------