Provider Demographics
NPI:1689972200
Name:HOLISTIC GYNECOLOGY OF THE TREASURECOAST
Entity Type:Organization
Organization Name:HOLISTIC GYNECOLOGY OF THE TREASURECOAST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MYLAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:RIOBE HERON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-266-4258
Mailing Address - Street 1:2100 SE OCEAN BLVD
Mailing Address - Street 2:STE 200-B
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34996-3332
Mailing Address - Country:US
Mailing Address - Phone:772-266-4258
Mailing Address - Fax:772-219-8111
Practice Address - Street 1:2100 SE OCEAN BLVD
Practice Address - Street 2:STE 200-B
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34996-3332
Practice Address - Country:US
Practice Address - Phone:772-266-4258
Practice Address - Fax:772-219-8111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-06
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82630261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H45592Medicare UPIN