Provider Demographics
NPI:1174303077
Name:MINDSHAPE CLINIC PLC
Entity type:Organization
Organization Name:MINDSHAPE CLINIC PLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HASSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-650-3031
Mailing Address - Street 1:2560 LYNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-5681
Mailing Address - Country:US
Mailing Address - Phone:515-650-3031
Mailing Address - Fax:515-219-4772
Practice Address - Street 1:2560 LYNWOOD DR STE 3
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-5681
Practice Address - Country:US
Practice Address - Phone:515-650-3031
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-29
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC00427241Medicaid
KY7100785550Medicaid