MEDICARE: MINDOULA CLINICAL SERVICES LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	171M00000X	Case Manager/Care Coordinator
2	251B00000X	Case Management Agency
3	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1770065047
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDOULA CLINICAL SERVICES LLC

Provider Business Mailing Address
First Line	:	1117 E WEST HWY
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20910-4852
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1117 E WEST HWY
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20910-4852
Country	:	US
Telephone Number	:	954-650-2802
Fax Number	:

Authorized Official
Title or Position	:	SVP OPERATIONS
Name	:	GREGORY COUTO
Credential	:
Telephone Number	:	954-650-2802

Provider Enumeration Date	:	09/04/2018
Last Update Date	:	08/10/2020

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Directions to “MINDOULA CLINICAL SERVICES LLC ” Practice Location

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