Provider Demographics
NPI:1053018903
Name:MIND BODY ENDURANCE LLC
Entity type:Organization
Organization Name:MIND BODY ENDURANCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RILEY
Authorized Official - Middle Name:
Authorized Official - Last Name:NICKOLS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:513-505-2160
Mailing Address - Street 1:16 N GORE AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-2315
Mailing Address - Country:US
Mailing Address - Phone:513-505-2160
Mailing Address - Fax:
Practice Address - Street 1:16 N GORE AVE STE 204
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-2315
Practice Address - Country:US
Practice Address - Phone:513-505-2160
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-10
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & SportsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1790019511Medicaid