Provider Demographics
NPI:1366908394
Name:HOLISTIC STUDIO WHITE LOTUS
Entity type:Organization
Organization Name:HOLISTIC STUDIO WHITE LOTUS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:IGOR
Authorized Official - Middle Name:
Authorized Official - Last Name:RYBIN
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:201-637-1045
Mailing Address - Street 1:2-06 CYRIL AVE
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-2003
Mailing Address - Country:US
Mailing Address - Phone:212-464-8407
Mailing Address - Fax:
Practice Address - Street 1:700 PALISADIUM DR
Practice Address - Street 2:
Practice Address - City:CLIFFSIDE PARK
Practice Address - State:NJ
Practice Address - Zip Code:07010-3239
Practice Address - Country:US
Practice Address - Phone:201-538-2373
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-14
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center