Provider Demographics
NPI:1215744198
Name:HOLISTIC INDIVIDUAL SUPPORT LIVING LLC
Entity type:Organization
Organization Name:HOLISTIC INDIVIDUAL SUPPORT LIVING LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOVIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BAYINGANA
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, DR
Authorized Official - Phone:207-518-7073
Mailing Address - Street 1:529 AURORA AVE
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-2816
Mailing Address - Country:US
Mailing Address - Phone:207-518-7073
Mailing Address - Fax:
Practice Address - Street 1:529 AURORA AVE
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-2816
Practice Address - Country:US
Practice Address - Phone:202-518-7073
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-14
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness