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General NPI Number Information
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NPI Number | 1548069859
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Entity Type | Organization
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Legal Business Name | MIND BODY OPTIMIZATION ONLINE, LLC
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Dates
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Enumeration Date | 03/10/2025
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Last Update Date | 11/24/2025
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Provider Practice Location Address
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Address Line | 5405 W 151ST ST
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City | LEAWOOD
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State | KS
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Zip | 66224-8700
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Country | US
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Telephone | 682-900-6631
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Fax | 682-503-7428
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Provider Business Mailing Address
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Address Line | 16 VILLAGE LN STE 200
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City | COLLEYVILLE
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State | TX
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Zip | 76034-2948
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Country | US
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Telephone | 682-900-6631
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Fax | 682-503-7428
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Authorized Official
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Title or Position | LEGAL COUNSEL
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Name | MR. DAVID J MORAINE
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Credential | ESQ
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Telephone | 469-990-3626
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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