Provider Demographics
NPI:1154503902
Name:HOLISTIC FAMILY HEALTH CLINIC, P.A.
Entity Type:Organization
Organization Name:HOLISTIC FAMILY HEALTH CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DOM, AP, CHT
Authorized Official - Phone:321-385-1000
Mailing Address - Street 1:PO BOX 259
Mailing Address - Street 2:
Mailing Address - City:SCOTTSMOOR
Mailing Address - State:FL
Mailing Address - Zip Code:32775-0259
Mailing Address - Country:US
Mailing Address - Phone:321-385-1000
Mailing Address - Fax:
Practice Address - Street 1:3620 S HOPKINS AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-5707
Practice Address - Country:US
Practice Address - Phone:321-385-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP1651261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC0840OtherBLUECROSS BLUESHIELD