MEDICARE: MINDFUL SPECIALTY ASSOCIATES

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	103T00000X	Psychologist
2	207R00000X	Internal Medicine Physician
3	2084P0800X	Psychiatry Physician
4	363A00000X	Physician Assistant
5	363L00000X	Nurse Practitioner
6	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1265183628
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDFUL SPECIALTY ASSOCIATES

Provider Business Mailing Address
First Line	:	24040 CAMINO DEL AVION STE E196
Second Line	:
City	:	DANA POINT
State	:	CA
Zip	:	92629-4005
Country	:	US
Telephone Number	:	714-617-0001
Fax Number	:

Provider Business Practice Location Address
First Line	:	24040 CAMINO DEL AVION STE E196
Second Line	:
City	:	DANA POINT
State	:	CA
Zip	:	92629-4005
Country	:	US
Telephone Number	:	714-617-0001
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	ROBERT HEINEMEIER
Credential	:
Telephone Number	:	714-617-0001

Provider Enumeration Date	:	01/17/2022
Last Update Date	:	01/19/2022

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