Provider Demographics
NPI:1518782663
Name:ELEMENTAL BODY & MIND LLC
Entity type:Organization
Organization Name:ELEMENTAL BODY & MIND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:HAVEN
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:502-649-1387
Mailing Address - Street 1:131 E COURT AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-3600
Mailing Address - Country:US
Mailing Address - Phone:812-408-3674
Mailing Address - Fax:812-407-8126
Practice Address - Street 1:131 E COURT AVE STE 100
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3600
Practice Address - Country:US
Practice Address - Phone:812-408-3674
Practice Address - Fax:812-407-8126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-22
Last Update Date:2025-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1376258418Medicaid
IN1841852118Medicaid