Provider Demographics
NPI:1336478890
Name:HOLISTIC MEDICAL AND WELLNESS CENTER OF IN, LLC
Entity Type:Organization
Organization Name:HOLISTIC MEDICAL AND WELLNESS CENTER OF IN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RANDEE
Authorized Official - Middle Name:L
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MSN APRN BC
Authorized Official - Phone:317-608-6090
Mailing Address - Street 1:8424 NAAB RD
Mailing Address - Street 2:SUITE 3P
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-5918
Mailing Address - Country:US
Mailing Address - Phone:317-608-6090
Mailing Address - Fax:317-608-6095
Practice Address - Street 1:8424 NAAB RD
Practice Address - Street 2:SUITE 3P
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-5918
Practice Address - Country:US
Practice Address - Phone:317-608-6090
Practice Address - Fax:317-608-6095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-12
Last Update Date:2009-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001160B261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200840870Medicaid
IN200840870Medicaid
IN220270BMedicare PIN