Healthcare Provider Details

I. General information

NPI: 1164059978
Provider Name (Legal Business Name): WHOLE HEALTH OSTEOPATHIC MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 10/14/2020
Certification Date: 10/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 FORE RIVER PKWY STE 407
PORTLAND ME
04102-2780
US

IV. Provider business mailing address

195 FORE RIVER PKWY STE 407
PORTLAND ME
04102-2780
US

V. Phone/Fax

Practice location:
  • Phone: 207-749-6612
  • Fax:
Mailing address:
  • Phone: 207-749-6612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN R GOLDBAS
Title or Position: OWNER
Credential: DO
Phone: 207-749-6612