Healthcare Provider Details

I. General information

NPI: 1740031343
Provider Name (Legal Business Name): HOLISTIC HORIZEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2024
Last Update Date: 04/01/2024
Certification Date: 03/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3830 N MAIN ST
HIGH POINT NC
27265-1126
US

IV. Provider business mailing address

1812 MCKNIGHT MILL RD APT B
GREENSBORO NC
27405-3970
US

V. Phone/Fax

Practice location:
  • Phone: 347-606-6460
  • Fax:
Mailing address:
  • Phone: 347-606-6460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHAQUILLE HENRY
Title or Position: OWNER/CEO
Credential:
Phone: 347-606-6460