=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740162155
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIND INFLUENCE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2025
-----------------------------------------------------
Last Update Date | 07/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3475 N DESERT DR STE 1104
-----------------------------------------------------
City | EAST POINT
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30344-5723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-262-6460
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3475 N DESERT DR STE 1104
-----------------------------------------------------
City | EAST POINT
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30344-5723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-262-6460
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ MASSAGE THERAPY
-----------------------------------------------------
Name | JOHN ROBERT MACK
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 470-262-6460
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------