MEDICARE: MIND BODY AND SOUL 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	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	101YP2500X	Professional Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NV20191215058	OTHER	NV	BUSINESS LICENSE

General Provider Information

NPI Number	:	1508325366
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIND BODY AND SOUL LLC

Provider Business Mailing Address
First Line	:	1405 SAN JUAN HILLS DR UNIT 105
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89134-6390
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1405 SAN JUAN HILLS DR UNIT 105
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89134-6390
Country	:	US
Telephone Number	:	770-341-4402
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	JEFFREY CARSON
Credential	:
Telephone Number	:	770-364-4402

Provider Enumeration Date	:	03/19/2019
Last Update Date	:	03/19/2019

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