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General NPI Number Information
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NPI Number | 1508138561
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Entity Type | Organization
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Legal Business Name | MIND BODY SPIRIT WELLNESS INC
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Dates
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Enumeration Date | 02/06/2012
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Last Update Date | 02/06/2012
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Provider Practice Location Address
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Address Line | 2801 BUFORD HWY NE STE T65
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City | ATLANTA
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State | GA
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Zip | 30329-2145
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Country | US
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Telephone | 404-478-9868
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Fax |
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Provider Business Mailing Address
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Address Line | 2484 BRIARCLIFF RD NE STE 22-315
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City | ATLANTA
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State | GA
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Zip | 30329-3011
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Country | US
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Telephone | 404-478-9868
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | MAIYSHA TANIA CLAIRBORNE
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Credential | MD
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Telephone | 404-478-9868
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 055194
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 055194
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License Number State | GA
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