Provider Demographics
NPI:1770747990
Name:MEDICAL HOLISTIC CENTER, LLC
Entity type:Organization
Organization Name:MEDICAL HOLISTIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:STEVENSON
Authorized Official - Suffix:
Authorized Official - Credentials:DOM
Authorized Official - Phone:386-663-3003
Mailing Address - Street 1:512 CANAL ST
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-7012
Mailing Address - Country:US
Mailing Address - Phone:386-663-3003
Mailing Address - Fax:386-663-3007
Practice Address - Street 1:512 CANAL ST
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-7012
Practice Address - Country:US
Practice Address - Phone:386-663-3003
Practice Address - Fax:386-663-3007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-16
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9438208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL279979100OtherMEDIPASS
FL279979100Medicaid
FL124970Medicare UPIN