=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689465544
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COUNTRY HOLISTICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2025
-----------------------------------------------------
Last Update Date | 05/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 39 N SCOTT ST STE 3
-----------------------------------------------------
City | SHERIDAN
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82801-6363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-429-9005
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 812 S MAIN ST
-----------------------------------------------------
City | SHERIDAN
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82801-5126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-429-9005
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SAMANTHA N HILL
-----------------------------------------------------
Credential | CMT
-----------------------------------------------------
Telephone | 307-429-9005
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------