MEDICARE: MIP SVC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1063288512
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIP SVC LLC

Provider Business Mailing Address
First Line	:	2200 NORTH LOOP W STE 106
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77018-1754
Country	:	US
Telephone Number	:	832-219-8536
Fax Number	:

Provider Business Practice Location Address
First Line	:	2200 NORTH LOOP W STE 106
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77018-1754
Country	:	US
Telephone Number	:	832-219-8536
Fax Number	:

Authorized Official
Title or Position	:	CO-FOUNDER
Name	:	DINA KUSHALIYEVA
Credential	:
Telephone Number	:	214-802-0224

Provider Enumeration Date	:	11/27/2023
Last Update Date	:	11/29/2023

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