1619033362 NPI number — WHOLISTIC MEDICINE CLIN

Table of content: (NPI 1619033362)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619033362 NPI number — WHOLISTIC MEDICINE CLIN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WHOLISTIC MEDICINE CLIN
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:
1619033362
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1405 SE GOLDTREE DR
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
PORT ST LUCIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34952-7563
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-335-5022
Provider Business Mailing Address Fax Number:
772-335-5029

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1405 SE GOLDTREE DR
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
PORT ST LUCIE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34952-7563
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-335-5022
Provider Business Practice Location Address Fax Number:
772-335-5029
Provider Enumeration Date:
12/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TYE
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
G
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
772-335-5022

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 94821 . This is a "BLUECROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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