MEDICARE: VILLAGES MIND AND BODY INSTITUTE

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	ADC-007797-2015	FL

General Provider Information

NPI Number	:	1881148393
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VILLAGES MIND AND BODY INSTITUTE

Provider Business Mailing Address
First Line	:	324 S US HIGHWAY 441
Second Line	:
City	:	LADY LAKE
State	:	FL
Zip	:	32159-4377
Country	:	US
Telephone Number	:	352-633-0614
Fax Number	:	866-684-9990

Provider Business Practice Location Address
First Line	:	324 S US HIGHWAY 441
Second Line	:
City	:	LADY LAKE
State	:	FL
Zip	:	32159-4377
Country	:	US
Telephone Number	:	352-633-0614
Fax Number	:	866-684-9990

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. TONYA MARIE HOUGHTON
Credential	:
Telephone Number	:	352-633-0614

Provider Enumeration Date	:	08/12/2016
Last Update Date	:	08/12/2016

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