1578974143 NPI number — MIND BODY PROFESSIONAL CENTER

Table of content: (NPI 1578974143)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578974143 NPI number — MIND BODY PROFESSIONAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIND BODY PROFESSIONAL CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578974143
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/16/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1331
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUYALLUP
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98371-0243
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-278-9292
Provider Business Mailing Address Fax Number:
253-604-6237

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15406 MERIDIAN E STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUYALLUP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98375-9504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-278-9292
Provider Business Practice Location Address Fax Number:
253-604-6237
Provider Enumeration Date:
05/16/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BEUTLER
Authorized Official First Name:
REBECCA
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
253-278-9292

Provider Taxonomy Codes

  • Taxonomy code: 103TC1900X , with the licence number:  PY60318110 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)