1417672171 NPI number — THE MENTALITY SPA

Table of content: (NPI 1417672171)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417672171 NPI number — THE MENTALITY SPA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE MENTALITY SPA
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:
1417672171
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/05/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2389 NAVAJO TRL SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30331-7059
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-994-9974
Provider Business Mailing Address Fax Number:
678-306-8663

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8319 OFFICE PARK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOUGLASVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30134-6936
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-994-9974
Provider Business Practice Location Address Fax Number:
678-306-8663
Provider Enumeration Date:
10/05/2022

Additional Information

Authorized Official

Authorized Official Last Name:
KENNER
Authorized Official First Name:
MELANIE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
404-994-9974

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1023761996 . This is a "NPI" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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