Provider Demographics
NPI:1023560109
Name:WHOLISTIC MEDICAL GROUP
Entity Type:Organization
Organization Name:WHOLISTIC MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:DUKE
Authorized Official - Last Name:MANSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DOM
Authorized Official - Phone:860-933-2155
Mailing Address - Street 1:1016 E COLUMBUS DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33605-3333
Mailing Address - Country:US
Mailing Address - Phone:860-933-2155
Mailing Address - Fax:
Practice Address - Street 1:3965 HENDERSON BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-5023
Practice Address - Country:US
Practice Address - Phone:813-444-3946
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP3763171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty