Provider Demographics
NPI:1083338909
Name:WHOLISTIC CENTER FOR RESTORATIVE HEALTH AND FUNCTIONAL MEDICINE PLLC
Entity Type:Organization
Organization Name:WHOLISTIC CENTER FOR RESTORATIVE HEALTH AND FUNCTIONAL MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAMILLE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-858-8480
Mailing Address - Street 1:19785 W 12 MILE RD # 591
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2584
Mailing Address - Country:US
Mailing Address - Phone:313-858-8480
Mailing Address - Fax:
Practice Address - Street 1:20905 GREENFIELD RD STE 600
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-5355
Practice Address - Country:US
Practice Address - Phone:586-879-1921
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service