Healthcare Provider Details

I. General information

NPI: 1124353339
Provider Name (Legal Business Name): PRO- HOLISM PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2009
Last Update Date: 07/16/2020
Certification Date: 07/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2480 WINDY HILL RD SE SUITE 206
MARIETTA GA
30067-8644
US

IV. Provider business mailing address

2480 WINDY HILL RD SE STE 206
MARIETTA GA
30067-8656
US

V. Phone/Fax

Practice location:
  • Phone: 770-953-0074
  • Fax:
Mailing address:
  • Phone: 404-800-5550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number StateGA
# 6
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number StateGA
# 7
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number StateFL
# 8
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateGA

VIII. Authorized Official

Name: DR. REDA COSTON
Title or Position: HEALTHCARE ADMINISTRATION EXECUTIVE
Credential: LMP, D.SC., PSYD/PHD
Phone: 404-800-5550