MEDICARE: MINDFUL MEDICINE COUNSELING CENTER LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QM0855X	Adolescent and Children Mental Health Clinic/Center
2	261QP2300X	Primary Care Clinic/Center
3	208000000X	Pediatrics Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1699834408	OTHER	FL	NPI NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912693912
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDFUL MEDICINE COUNSELING CENTER LLC

Provider Business Mailing Address
First Line	:	3914 DYLAN CT
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32223-2707
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10365 HOOD RD S STE 204
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32257-3261
Country	:	US
Telephone Number	:	217-480-7298
Fax Number	:

Authorized Official
Title or Position	:	COO
Name	:	ROMAN CRIOLLO
Credential	:	MD
Telephone Number	:	217-480-7298

Provider Enumeration Date	:	04/12/2023
Last Update Date	:	11/11/2023

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