MEDICARE: HOLISTIC FAMILY & PAIN MANAGEMENT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	ME91383	FL

General Provider Information

NPI Number	:	1003145301
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOLISTIC FAMILY & PAIN MANAGEMENT

Provider Business Mailing Address
First Line	:	1905 S 25TH ST
Second Line	:	STE100
City	:	FORT PIERCE
State	:	FL
Zip	:	34947-4739
Country	:	US
Telephone Number	:	772-467-9083
Fax Number	:	772-464-6478

Provider Business Practice Location Address
First Line	:	1905 S 25TH ST
Second Line	:	STE100
City	:	FORT PIERCE
State	:	FL
Zip	:	34947-4739
Country	:	US
Telephone Number	:	772-467-9083
Fax Number	:	772-464-6478

Authorized Official
Title or Position	:	OWNER
Name	:	DR. WILLIAM G TYE III
Credential	:	DOM
Telephone Number	:	772-467-9083

Provider Enumeration Date	:	12/15/2009
Last Update Date	:	12/15/2009

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