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General NPI Number Information
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NPI Number | 1811405616
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Entity Type | Organization
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Legal Business Name | HOLISTIC, INC
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Dates
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Enumeration Date | 01/15/2018
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Last Update Date | 08/22/2023
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Provider Practice Location Address
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Address Line | 4815 MACCORKLE AVE SE
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City | CHARLESTON
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State | WV
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Zip | 25304-1948
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Country | US
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Telephone | 681-265-1693
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Fax | 681-265-0990
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Provider Business Mailing Address
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Address Line | 7 ANCHORS WAY
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City | WINFIELD
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State | WV
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Zip | 25213-9786
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Country | US
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Telephone | 304-553-1576
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. SHAWN ROBERT BLANKENSHIP
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Credential | NURSE PRACTITIONER
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Telephone | 304-553-1576
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State | WV
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Taxonomy #2
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number |
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License Number State | WV
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