Provider Demographics
NPI:1376296301
Name:PANACHE HOLISTICS
Entity Type:Organization
Organization Name:PANACHE HOLISTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:PROVENCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-839-4997
Mailing Address - Street 1:2552 BARCELONA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33905-2212
Mailing Address - Country:US
Mailing Address - Phone:239-410-6250
Mailing Address - Fax:
Practice Address - Street 1:2552 BARCELONA AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-2212
Practice Address - Country:US
Practice Address - Phone:239-410-6250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances