1891369823 NPI number — HOLISTIC WELLNESS GROUP, LLC

Table of content: (NPI 1891369823)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891369823 NPI number — HOLISTIC WELLNESS GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOLISTIC WELLNESS GROUP, LLC
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:
6
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:
1891369823
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/31/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
125 COBB DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JEMISON
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35085-4197
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-430-9966
Provider Business Mailing Address Fax Number:
915-223-1562

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
808 LAY DAM RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLANTON
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35045-2943
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-369-1273
Provider Business Practice Location Address Fax Number:
205-369-1273
Provider Enumeration Date:
05/14/2021

Additional Information

Authorized Official

Authorized Official Last Name:
ASHLEY
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESCRIBER/MEMBER
Authorized Official Telephone Number:
205-430-9966

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 270189 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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