Provider Demographics
NPI:1427342534
Name:MINDBODY MEDICINE PLLC
Entity type:Organization
Organization Name:MINDBODY MEDICINE PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:LEWIS
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:480-607-7999
Mailing Address - Street 1:13951 N SCOTTSDALE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-3452
Mailing Address - Country:US
Mailing Address - Phone:480-607-7999
Mailing Address - Fax:480-607-7998
Practice Address - Street 1:13951 N SCOTTSDALE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-3452
Practice Address - Country:US
Practice Address - Phone:480-607-7999
Practice Address - Fax:480-607-7998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-06
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27969261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center