Provider Demographics
NPI:1992419527
Name:MIND BODY SOUL WEIGHT REDUCTION CLINIC
Entity type:Organization
Organization Name:MIND BODY SOUL WEIGHT REDUCTION CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIMAKA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-347-1023
Mailing Address - Street 1:PO BOX 313
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-0313
Mailing Address - Country:US
Mailing Address - Phone:601-347-1023
Mailing Address - Fax:
Practice Address - Street 1:296 BEAUVOIR RD # 319
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-4051
Practice Address - Country:US
Practice Address - Phone:601-347-1023
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
1689067324OtherNPI