1942516844 NPI number — MIND AND BRAIN CARE LLC

Table of content: (NPI 1942516844)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942516844 NPI number — MIND AND BRAIN CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIND AND BRAIN CARE 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:
1942516844
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10175 6 MILE CYPRESS PKWY
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33966-9663
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-768-6500
Provider Business Mailing Address Fax Number:
239-768-6421

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10175 6 MILE CYPRESS PKWY STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33966-6993
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-768-6500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/30/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LOPEZ
Authorized Official First Name:
MABEL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
239-768-6500

Provider Taxonomy Codes

  • Taxonomy code: 103G00000X , with the licence number:  PY7375 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TB0200X , with the licence number: PY7375 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: PY7375 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC1900X , with the licence number: PY7375 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC2200X , with the licence number: PY7375 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TF0200X , with the licence number: PY7375 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TM1800X , with the licence number: PY7375 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 75725 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 6022640 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".