Provider Demographics
NPI:1962184341
Name:ULTIMATE MIND AND WELLNESS CENTER, LLC
Entity type:Organization
Organization Name:ULTIMATE MIND AND WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRISTAR
Authorized Official - Middle Name:
Authorized Official - Last Name:MBC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:682-219-4077
Mailing Address - Street 1:1108 W PIONEER PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76013-7627
Mailing Address - Country:US
Mailing Address - Phone:682-219-4077
Mailing Address - Fax:
Practice Address - Street 1:1108 W PIONEER PKWY STE 100
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76013-7627
Practice Address - Country:US
Practice Address - Phone:321-320-7512
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-03
Last Update Date:2024-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty