1366271512 NPI number — BRAIN BODY SOUL THERAPY AND WELLNESS LLC

Table of content: (NPI 1366271512)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366271512 NPI number — BRAIN BODY SOUL THERAPY AND WELLNESS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRAIN BODY SOUL THERAPY AND WELLNESS 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:
1366271512
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2834 E 90TH ST UNIT 1806
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74137-3377
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-646-4354
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2488 E 81ST ST STE 4821
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TULSA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74137-4290
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-236-0833
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/27/2024

Additional Information

Authorized Official

Authorized Official Last Name:
RAYMOND
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
CARSON
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
918-236-0833

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200946240B , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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