Provider Demographics
NPI:1487469961
Name:MIND BODY SOUL REVIVAL LLC
Entity type:Organization
Organization Name:MIND BODY SOUL REVIVAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:EMMA
Authorized Official - Middle Name:
Authorized Official - Last Name:O'CONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, CEDS
Authorized Official - Phone:774-270-7018
Mailing Address - Street 1:845 VANCE ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80214-4828
Mailing Address - Country:US
Mailing Address - Phone:774-270-7018
Mailing Address - Fax:
Practice Address - Street 1:845 VANCE ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80214-4828
Practice Address - Country:US
Practice Address - Phone:774-270-7018
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-11
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Single Specialty