Healthcare Provider Details

I. General information

NPI: 1053910620
Provider Name (Legal Business Name): HOLISTIC FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2020
Last Update Date: 10/23/2020
Certification Date: 10/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 SIERRA ROSE DR STE 102A
RENO NV
89511-4030
US

IV. Provider business mailing address

645 SIERRA ROSE DR STE 102A
RENO NV
89511-4030
US

V. Phone/Fax

Practice location:
  • Phone: 775-386-9010
  • Fax:
Mailing address:
  • Phone: 775-386-9010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KRYSTAL R PETERS
Title or Position: APRN
Credential: APRN
Phone: 775-386-9010