1902057797 NPI number — MIND BODY SPIRIT CENTER

Table of content: (NPI 1902057797)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902057797 NPI number — MIND BODY SPIRIT CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIND BODY SPIRIT 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:
1902057797
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
160 WAYNESBOROUGH WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANKATO
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56001-6457
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-625-2660
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
160 WAYNESBOROUGH WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANKATO
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56001-6457
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-625-2660
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/10/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LOWINSKE
Authorized Official First Name:
CAROL ANN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
507-625-2660

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  LP3920 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1975170-00 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 125732 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 45Q33L0 . This is a "BLUE CROSS BLUE SHEILD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 62-51173 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".