Provider Demographics
NPI:1639657463
Name:HOLY LIFESTYLES REHAB AND WELLNESS, LLC
Entity Type:Organization
Organization Name:HOLY LIFESTYLES REHAB AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LATISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:317-721-8079
Mailing Address - Street 1:6923 BRETTON WOOD DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-2771
Mailing Address - Country:US
Mailing Address - Phone:317-721-8079
Mailing Address - Fax:
Practice Address - Street 1:5356 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-3461
Practice Address - Country:US
Practice Address - Phone:317-721-8079
Practice Address - Fax:317-732-7585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-03
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty