Provider Demographics
NPI:1679785240
Name:EAST WEST HOLISTIC MEDICINE CLINIC LLC
Entity type:Organization
Organization Name:EAST WEST HOLISTIC MEDICINE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:NATALYA
Authorized Official - Middle Name:
Authorized Official - Last Name:KLYUCHKO
Authorized Official - Suffix:
Authorized Official - Credentials:AP
Authorized Official - Phone:772-600-0073
Mailing Address - Street 1:506 SW FEDERAL HWY
Mailing Address - Street 2:SUITE101
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-2827
Mailing Address - Country:US
Mailing Address - Phone:772-600-7033
Mailing Address - Fax:
Practice Address - Street 1:506 SW FEDERAL HWY
Practice Address - Street 2:SUITE 101
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2827
Practice Address - Country:US
Practice Address - Phone:772-600-7033
Practice Address - Fax:772-600-7083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAD112Medicare PIN