Provider Demographics
NPI:1548069859
Name:MIND BODY OPTIMIZATION ONLINE, LLC
Entity type:Organization
Organization Name:MIND BODY OPTIMIZATION ONLINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LEGAL COUNSEL
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:MORAINE
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:469-990-3626
Mailing Address - Street 1:16 VILLAGE LN STE 200
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-2948
Mailing Address - Country:US
Mailing Address - Phone:682-900-6631
Mailing Address - Fax:682-503-7500
Practice Address - Street 1:16 VILLAGE LN STE 200
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-2948
Practice Address - Country:US
Practice Address - Phone:682-900-6631
Practice Address - Fax:682-503-7500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-10
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty