MEDICARE: MIND BODY NOURISH 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	363LA2200X	Adult Health Nurse Practitioner

General Provider Information

NPI Number	:	1740090026
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIND BODY NOURISH LLC

Provider Business Mailing Address
First Line	:	2901 MEREDITH PL
Second Line	:
City	:	BENSALEM
State	:	PA
Zip	:	19020-2258
Country	:	US
Telephone Number	:	267-455-9230
Fax Number	:

Provider Business Practice Location Address
First Line	:	2625 W GIRARD AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19130-1333
Country	:	US
Telephone Number	:	305-930-2967
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. ANISA ORTIZ
Credential	:	CRNP
Telephone Number	:	305-930-2967

Provider Enumeration Date	:	01/09/2025
Last Update Date	:	01/09/2025

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