Basic Information
| Provider Information | |||||||||
| NPI: | 1558843813 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MINDOULA HEALTH INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1117 E WEST HWY | ||||||||
| Address2: | |||||||||
| City: | SILVER SPRING | ||||||||
| State: | MD | ||||||||
| PostalCode: | 209104852 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1117 E WEST HWY | ||||||||
| Address2: | |||||||||
| City: | SILVER SPRING | ||||||||
| State: | MD | ||||||||
| PostalCode: | 209104852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0000000000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2018 | ||||||||
| LastUpdateDate: | 08/24/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COUTO | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SVP OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 9546502802 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator | 251B00000X | MD | N | Agencies | Case Management | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 951032000 | 05 | MD | MEDICAID | 1558843813 | 05 | NC | MEDICAID | 250004132 | 05 | NV | MEDICAID |