1609528272 NPI number — MIND REPOSE LLC

Table of content: (NPI 1609528272)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609528272 NPI number — MIND REPOSE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIND REPOSE LLC
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:
1609528272
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 3RD AVE STE 1143
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10022-7649
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-300-2655
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 W SCENIC DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PASS CHRISTIAN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39571-4420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-300-2655
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/25/2022

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CASE
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
480-300-2655

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 102L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TB0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC1900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TP0016X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TP0814X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TP2701X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TR0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 163WA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QA0401X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084A0401X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 324500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1134710817 . This is a "STATE OF MISSISSIPPI" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".