Healthcare Provider Details

I. General information

NPI: 1104782689
Provider Name (Legal Business Name): PHOENIX HOLISTIC & NUTRITIONAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2025
Last Update Date: 12/29/2025
Certification Date: 12/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 N ORCHARD ST
IPAVA IL
61441-5289
US

IV. Provider business mailing address

10 N ORCHARD ST
IPAVA IL
61441-5289
US

V. Phone/Fax

Practice location:
  • Phone: 309-204-5133
  • Fax:
Mailing address:
  • Phone: 309-204-5133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code173C00000X
TaxonomyReflexologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225600000X
TaxonomyDance Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code332U00000X
TaxonomyHome Delivered Meals
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name: MS. TONYA L DAVIS
Title or Position: OWNER
Credential: ND
Phone: 331-264-0736