1699973628 NPI number — MIND CLINIC INC

Table of content: (NPI 1699973628)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699973628 NPI number — MIND CLINIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIND CLINIC INC
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:
1699973628
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/26/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8323
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCOTTSDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85252-8323
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-354-6463
Provider Business Mailing Address Fax Number:
480-354-6480

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10238 E HAMPTON AVE
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85209-3316
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-354-6463
Provider Business Practice Location Address Fax Number:
480-354-6480
Provider Enumeration Date:
07/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SHAREEF
Authorized Official First Name:
YASIR
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESICENT
Authorized Official Telephone Number:
480-354-6463

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  4446 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1376151-0 . This is a "CORPORATION NUMBER" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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