Healthcare Provider Details

I. General information

NPI: 1689135964
Provider Name (Legal Business Name): HOLISTIC HEALTH & DETOX CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2019
Last Update Date: 09/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2016 S ELIZABETH ST
KOKOMO IN
46902-2430
US

IV. Provider business mailing address

2016 S ELIZABETH ST
KOKOMO IN
46902-2430
US

V. Phone/Fax

Practice location:
  • Phone: 765-450-4776
  • Fax: 765-450-4776
Mailing address:
  • Phone: 765-450-4776
  • Fax: 765-450-4776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MIKA J FUJII
Title or Position: DIRECTOR
Credential: MD
Phone: 765-450-4776