MEDICARE: MIND FORWARD HEALTH CENTER, PLLC

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	261QM1300X	Multi-Specialty Clinic/Center
2	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1427780253
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIND FORWARD HEALTH CENTER, PLLC

Provider Business Mailing Address
First Line	:	2150 TRAWOOD DR STE B161
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79935-3322
Country	:	US
Telephone Number	:	915-832-1702
Fax Number	:	915-666-4409

Provider Business Practice Location Address
First Line	:	2150 TRAWOOD DR STE B161
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79935-3322
Country	:	US
Telephone Number	:	915-832-1702
Fax Number	:	915-666-4409

Authorized Official
Title or Position	:	OWNER
Name	:	VIRIDIANA ORTIZ
Credential	:	LCSW
Telephone Number	:	915-832-1702

Provider Enumeration Date	:	06/29/2022
Last Update Date	:	12/19/2022

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