Provider Demographics
NPI:1619033362
Name:WHOLISTIC MEDICINE CLIN
Entity Type:Organization
Organization Name:WHOLISTIC MEDICINE CLIN
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:772-335-5022
Mailing Address - Street 1:1405 SE GOLDTREE DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7563
Mailing Address - Country:US
Mailing Address - Phone:772-335-5022
Mailing Address - Fax:772-335-5029
Practice Address - Street 1:1405 SE GOLDTREE DR
Practice Address - Street 2:SUITE D
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7563
Practice Address - Country:US
Practice Address - Phone:772-335-5022
Practice Address - Fax:772-335-5029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL94821OtherBLUECROSS BLUE SHIELD
FLK4343Medicare ID - Type Unspecified