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General NPI Number Information
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NPI Number | 1770122277
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Entity Type | Organization
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Legal Business Name | MIND & BODY HEALTHCARE LLC
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Dates
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Enumeration Date | 12/31/2019
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Last Update Date | 01/08/2020
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Provider Practice Location Address
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Address Line | 1700 N UNION AVE
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City | ROSWELL
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State | NM
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Zip | 88201-3267
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Country | US
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Telephone | 575-489-4750
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Fax | 575-586-4414
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Provider Business Mailing Address
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Address Line | 714 GARDEN PL
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City | ROSWELL
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State | NM
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Zip | 88201-7767
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Country | US
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Telephone | 575-489-4750
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Fax | 575-586-4414
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Authorized Official
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Title or Position | OWNER
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Name | JON E PERRY
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Credential | PA
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Telephone | 575-489-4750
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/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 | 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 #3
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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