Provider Demographics
NPI:1700971504
Name:HOLISTIC GYNECOLOGY, INC
Entity Type:Organization
Organization Name:HOLISTIC GYNECOLOGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUAQUITA
Authorized Official - Middle Name:D
Authorized Official - Last Name:CALLAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-205-0405
Mailing Address - Street 1:1681 FRAZIER PARK DR.
Mailing Address - Street 2:DECATUR
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-0398
Mailing Address - Country:US
Mailing Address - Phone:404-216-4581
Mailing Address - Fax:678-205-0416
Practice Address - Street 1:2785 LAWRENCEVILLE HWY
Practice Address - Street 2:SUITE 107
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-2515
Practice Address - Country:US
Practice Address - Phone:678-205-0405
Practice Address - Fax:678-205-0416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033289174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7530Medicare ID - Type UnspecifiedPROVIDER IDENTIFICATION N