Provider Demographics
NPI:1154487874
Name:WHOLISTIC MEDICINE CLINIC OF PALM BEACH GARDENS, LLC
Entity Type:Organization
Organization Name:WHOLISTIC MEDICINE CLINIC OF PALM BEACH GARDENS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:G
Authorized Official - Last Name:TYE
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:772-287-2677
Mailing Address - Street 1:3385 BURNS RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-4328
Mailing Address - Country:US
Mailing Address - Phone:561-624-9360
Mailing Address - Fax:
Practice Address - Street 1:3385 BURNS RD
Practice Address - Street 2:SUITE 101
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-4328
Practice Address - Country:US
Practice Address - Phone:561-624-9360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL24569OtherBLUECROSS BLUESHIELD
FLK9805Medicare ID - Type Unspecified