Provider Demographics
NPI:1154067007
Name:CJ12 HOLISTIC HEALING CENTER
Entity Type:Organization
Organization Name:CJ12 HOLISTIC HEALING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:TERHAAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-242-8895
Mailing Address - Street 1:11907 STONE BLUFF DR
Mailing Address - Street 2:
Mailing Address - City:GRAND LEDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48837-2435
Mailing Address - Country:US
Mailing Address - Phone:517-242-8895
Mailing Address - Fax:
Practice Address - Street 1:11907 STONE BLUFF DR
Practice Address - Street 2:
Practice Address - City:GRAND LEDGE
Practice Address - State:MI
Practice Address - Zip Code:48837-2435
Practice Address - Country:US
Practice Address - Phone:517-242-8895
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-12
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)