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General NPI Number Information
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NPI Number | 1700971504
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Entity Type | Organization
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Legal Business Name | HOLISTIC GYNECOLOGY, INC
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Dates
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Enumeration Date | 10/04/2006
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Last Update Date | 04/28/2020
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Provider Practice Location Address
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Address Line | 2785 LAWRENCEVILLE HWY SUITE 107
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City | DECATUR
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State | GA
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Zip | 30033-2515
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Country | US
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Telephone | 678-205-0405
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Fax | 678-205-0416
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Provider Business Mailing Address
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Address Line | 1681 FRAZIER PARK DR. DECATUR
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City | DECATUR
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State | GA
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Zip | 30033-0398
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Country | US
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Telephone | 404-216-4581
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Fax | 678-205-0416
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Authorized Official
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Title or Position | OWNER
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Name | JUAQUITA D CALLAWAY
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Credential | MD
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Telephone | 678-205-0405
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 033289
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License Number State | GA
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