Provider Demographics
NPI:1104638519
Name:MIND BODY SPLENDID SUN
Entity type:Organization
Organization Name:MIND BODY SPLENDID SUN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:MICHEAL
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-791-7529
Mailing Address - Street 1:100 MIDDLETOWN PKWY UNIT 202
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21769-7767
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:185 MONTREAL WAY
Practice Address - Street 2:
Practice Address - City:FALLING WATERS
Practice Address - State:WV
Practice Address - Zip Code:25419-0109
Practice Address - Country:US
Practice Address - Phone:681-242-3799
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-22
Last Update Date:2025-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty