Healthcare Provider Details

I. General information

NPI: 1699520569
Provider Name (Legal Business Name): HOLISTIC & PAIN MEDICAL SPA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2024
Last Update Date: 04/23/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 E 12 MILE RD STE 2
MADISON HEIGHTS MI
48071-2648
US

IV. Provider business mailing address

PO BOX 356
SOUTHFIELD MI
48037-0356
US

V. Phone/Fax

Practice location:
  • Phone: 248-629-6242
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM GONTE
Title or Position: OWNER
Credential:
Phone: 248-629-6242