Provider Demographics
NPI:1699108860
Name:HOLISTIC GERIATRIC CARE LLC
Entity type:Organization
Organization Name:HOLISTIC GERIATRIC CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:S
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:601-527-7585
Mailing Address - Street 1:10026 LIZELIA RD
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39305-9595
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10026 LIZELIA RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39305-9595
Practice Address - Country:US
Practice Address - Phone:601-527-7585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-12
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04689005Medicaid
MS04689005Medicaid