1619268729 NPI number — MINDFUL HEALTH ADVANTAGE, LLC

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 1619268729 NPI number — MINDFUL HEALTH ADVANTAGE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MINDFUL HEALTH ADVANTAGE, 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:
1619268729
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
777 S WADSWORTH BLVD
Provider Second Line Business Mailing Address:
BLDG 2, STE 103
Provider Business Mailing Address City Name:
LAKEWOOD
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80226-4300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-202-6143
Provider Business Mailing Address Fax Number:
303-202-6146

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
777 S WADSWORTH BLVD
Provider Second Line Business Practice Location Address:
BLDG 2, STE 103
Provider Business Practice Location Address City Name:
LAKEWOOD
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80226-4300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-202-6143
Provider Business Practice Location Address Fax Number:
303-202-6146
Provider Enumeration Date:
04/22/2011

Additional Information

Authorized Official

Authorized Official Last Name:
PRICE
Authorized Official First Name:
TRACY
Authorized Official Middle Name:
JOHN
Authorized Official Title or Position:
MEMBER/PSYCHOLOGIST
Authorized Official Telephone Number:
303-202-6143

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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