Basic Information
| Provider Information | |||||||||
| NPI: | 1306005525 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIND YOUR BODY CLINIC PLLC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 97115 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984970115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535887911 | ||||||||
| FaxNumber: | 2539846774 | ||||||||
| Practice Location | |||||||||
| Address1: | 3819 100TH ST SW | ||||||||
| Address2: | SUITE 7-C | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984994470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535887911 | ||||||||
| FaxNumber: | 2539846774 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2008 | ||||||||
| LastUpdateDate: | 06/03/2008 | ||||||||
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| AuthorizedOfficialLastName: | JUTLA | ||||||||
| AuthorizedOfficialFirstName: | RAJNINDER | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2535887911 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD00047987 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.