Basic Information
| Provider Information | |||||||||
| NPI: | 1639732894 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOLISTIC HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1290 CAROLINE DR | ||||||||
| Address2: | |||||||||
| City: | TERRY | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391705000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014055131 | ||||||||
| FaxNumber: | 6018789909 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 MILLS ST | ||||||||
| Address2: | |||||||||
| City: | BROOKHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396012521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018335608 | ||||||||
| FaxNumber: | 6018789909 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2019 | ||||||||
| LastUpdateDate: | 02/22/2021 | ||||||||
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| AuthorizedOfficialLastName: | MCLEAN | ||||||||
| AuthorizedOfficialFirstName: | VICKY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6014055131 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 02/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.