1295146389 NPI number — MONADNOCK MIND AND BODY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295146389 NPI number — MONADNOCK MIND AND BODY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MONADNOCK MIND AND BODY
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:
1295146389
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/12/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3169 NC 8 HWY S
Provider Second Line Business Mailing Address:
AUTUMN SQUARE SUITE #201
Provider Business Mailing Address City Name:
WALNUT COVE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27052-5693
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-409-5178
Provider Business Mailing Address Fax Number:
866-376-2925

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3169 NC 8 HWY S
Provider Second Line Business Practice Location Address:
AUTUMN SQUARE SUITE #201
Provider Business Practice Location Address City Name:
WALNUT COVE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27052-5693
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-409-5178
Provider Business Practice Location Address Fax Number:
866-376-2925
Provider Enumeration Date:
05/12/2014

Additional Information

Authorized Official

Authorized Official Last Name:
MORROW
Authorized Official First Name:
VICKI
Authorized Official Middle Name:
O
Authorized Official Title or Position:
PSYCHIATRIST
Authorized Official Telephone Number:
336-409-5178

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  2012-01667 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5921708 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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