1225194665 NPI number — HOLISTIC WELLNESS NOW, PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225194665 NPI number — HOLISTIC WELLNESS NOW, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOLISTIC WELLNESS NOW, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225194665
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
820 W LAKE MARY BLVD
Provider Second Line Business Mailing Address:
SUITE 107
Provider Business Mailing Address City Name:
SANFORD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32773-5946
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-330-0240
Provider Business Mailing Address Fax Number:
407-330-9432

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
820 W LAKE MARY BLVD
Provider Second Line Business Practice Location Address:
107
Provider Business Practice Location Address City Name:
SANFORD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32773-5946
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-330-0240
Provider Business Practice Location Address Fax Number:
407-330-9432
Provider Enumeration Date:
12/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WIEDER
Authorized Official First Name:
NEAL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
407-330-0240

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  CH3063 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: CH3063 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1194299950 . This is a "STATE OF OHIO WORK COMP" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0166185 . This is a "BCBS OF TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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