Provider Demographics
NPI:1750447405
Name:WHOLISTIC MEDICINE CLINIC, LLC
Entity Type:Organization
Organization Name:WHOLISTIC MEDICINE CLINIC, LLC
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:772-287-2677
Mailing Address - Street 1:2401 FRIST BLVD
Mailing Address - Street 2:SUITE 7
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-4839
Mailing Address - Country:US
Mailing Address - Phone:772-467-9043
Mailing Address - Fax:772-464-6478
Practice Address - Street 1:2401 FRIST BLVD
Practice Address - Street 2:SUITE 7
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-4839
Practice Address - Country:US
Practice Address - Phone:772-467-9043
Practice Address - Fax:772-464-6478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL24565OtherBLUECROSS BLUE SHIELD
FL24565OtherBLUECROSS BLUE SHIELD