Healthcare Provider Details

I. General information

NPI: 1780224295
Provider Name (Legal Business Name): PEDIATRIC HOLISTIC WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2020
Last Update Date: 11/15/2021
Certification Date: 11/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 SOUTHPOINTE CT STE 145
COLORADO SPRINGS CO
80906-3877
US

IV. Provider business mailing address

635 SOUTHPOINTE CT STE 145
COLORADO SPRINGS CO
80906-3877
US

V. Phone/Fax

Practice location:
  • Phone: 719-510-5302
  • Fax:
Mailing address:
  • Phone: 719-510-5302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: LINDA MARGRAVE
Title or Position: OWNER
Credential:
Phone: 719-510-5302