Healthcare Provider Details

I. General information

NPI: 1578078275
Provider Name (Legal Business Name): HOLISTIC MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2017
Last Update Date: 12/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 MASSACHUSETTS AVE
CAMBRIDGE MA
02140-1628
US

IV. Provider business mailing address

19 HAMPSHIRE RD
WAYLAND MA
01778-1005
US

V. Phone/Fax

Practice location:
  • Phone: 617-661-6225
  • Fax:
Mailing address:
  • Phone: 508-358-1005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code175L00000X
TaxonomyHomeopath
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code2083T0002X
TaxonomyMedical Toxicology (Preventive Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. LEONID GORDIN
Title or Position: OWNER
Credential: MD
Phone: 617-661-6225