Provider Demographics
NPI:1568265205
Name:MIP SA LLC
Entity type:Organization
Organization Name:MIP SA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
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 1:901 NE LOOP 410 # 405
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-1305
Mailing Address - Country:US
Mailing Address - Phone:210-926-5502
Mailing Address - Fax:
Practice Address - Street 1:901 NE LOOP 410 # 405
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-1305
Practice Address - Country:US
Practice Address - Phone:210-926-5502
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIP SVC LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-03-28
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health