=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588211577
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOLISTIC MEDICAL SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2019
-----------------------------------------------------
Last Update Date | 04/03/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 NEW RD STE 210
-----------------------------------------------------
City | LINWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08221-1200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-601-2159
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 929 SANDY CIR
-----------------------------------------------------
City | MANAHAWKIN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08050-2551
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DOMINIC SEMBELLO
-----------------------------------------------------
Credential | L.AC.
-----------------------------------------------------
Telephone | 609-248-6922
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------