Healthcare Provider Details

I. General information

NPI: 1407490170
Provider Name (Legal Business Name): HOLISTIC VIRTUAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2019
Last Update Date: 11/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3439 SE HAWTHORNE BLVD # 906
PORTLAND OR
97214-5048
US

IV. Provider business mailing address

539 W COMMERCE ST # 901
DALLAS TX
75208-1953
US

V. Phone/Fax

Practice location:
  • Phone: 971-999-2182
  • Fax:
Mailing address:
  • Phone: 971-999-2182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WN1003X
TaxonomyNutrition Support Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: CHANDAN SHARMA
Title or Position: MANAGER
Credential:
Phone: 971-999-2182