Provider Demographics
NPI:1528246295
Name:MIND BODY MEDICINE INC.
Entity type:Organization
Organization Name:MIND BODY MEDICINE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:G
Authorized Official - Last Name:KOHLS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:218-628-2130
Mailing Address - Street 1:8 N 2ND AVE E
Mailing Address - Street 2:SUITE 209
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-2102
Mailing Address - Country:US
Mailing Address - Phone:218-628-2130
Mailing Address - Fax:
Practice Address - Street 1:8 N 2ND AVE E
Practice Address - Street 2:SUITE 209
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-2102
Practice Address - Country:US
Practice Address - Phone:218-628-2130
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN40M27KOOtherBLUE CROSS