Healthcare Provider Details

I. General information

NPI: 1689972200
Provider Name (Legal Business Name): HOLISTIC GYNECOLOGY OF THE TREASURECOAST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2011
Last Update Date: 04/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 SE OCEAN BLVD STE 200-B
STUART FL
34996-3332
US

IV. Provider business mailing address

2100 SE OCEAN BLVD STE 200-B
STUART FL
34996-3332
US

V. Phone/Fax

Practice location:
  • Phone: 772-266-4258
  • Fax: 772-219-8111
Mailing address:
  • Phone: 772-266-4258
  • Fax: 772-219-8111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberME82630
License Number StateFL

VIII. Authorized Official

Name: MYLAINE RIOBE HERON
Title or Position: OWNER/DIRECTOR
Credential: MD
Phone: 772-266-4258