=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992503544
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINDCARE SOLUTIONS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2025
-----------------------------------------------------
Last Update Date | 03/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4414 PHEASANT RIDGE RD
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24014-5276
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-319-4240
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3102 W END AVE STE 1150
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37203-1614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-319-4240
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SR VP OF REVENUE OPERATIONS
-----------------------------------------------------
Name | BRIAN NICHOLS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 330-319-4240
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------