Provider Demographics
NPI:1063288512
Name:MIP SVC LLC
Entity type:Organization
Organization Name:MIP SVC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:DINA
Authorized Official - Middle Name:
Authorized Official - Last Name:KUSHALIYEVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-802-0224
Mailing Address - Street 1:2200 NORTH LOOP W STE 106
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77018-1754
Mailing Address - Country:US
Mailing Address - Phone:832-219-8536
Mailing Address - Fax:
Practice Address - Street 1:2200 NORTH LOOP W STE 106
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77018-1754
Practice Address - Country:US
Practice Address - Phone:832-219-8536
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-27
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health