Provider Demographics
NPI:1962235796
Name:WHOLISTICALLY DIVINE
Entity type:Organization
Organization Name:WHOLISTICALLY DIVINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:CD
Authorized Official - Phone:614-381-1359
Mailing Address - Street 1:185 HEFFRON CIR
Mailing Address - Street 2:
Mailing Address - City:MAINEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45039-7342
Mailing Address - Country:US
Mailing Address - Phone:614-381-1359
Mailing Address - Fax:
Practice Address - Street 1:185 HEFFRON CIR
Practice Address - Street 2:
Practice Address - City:MAINEVILLE
Practice Address - State:OH
Practice Address - Zip Code:45039-7342
Practice Address - Country:US
Practice Address - Phone:614-381-1359
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-26
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No251B00000XAgenciesCase Management
No251K00000XAgenciesPublic Health or Welfare
No261QB0400XAmbulatory Health Care FacilitiesClinic/CenterBirthing