MEDICARE: MINDFUL NUTRITION AND WELLNESS 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	305S00000X	Point of Service

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1669082525	OTHER		TYPE I NPI

General Provider Information

NPI Number	:	1427661719
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDFUL NUTRITION AND WELLNESS LLC

Provider Business Mailing Address
First Line	:	15 BRENTHAM RD
Second Line	:
City	:	NORTH BILLERICA
State	:	MA
Zip	:	01862-1126
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	14 FLETCHER ST
Second Line	:
City	:	CHELMSFORD
State	:	MA
Zip	:	01824-2713
Country	:	US
Telephone Number	:	978-254-3599
Fax Number	:

Authorized Official
Title or Position	:	CEO/OWNER
Name	:	JENELLE INDELICATO
Credential	:
Telephone Number	:	978-254-3599

Provider Enumeration Date	:	08/26/2020
Last Update Date	:	08/26/2020

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