MEDICARE: PANACHE HOLISTICS

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	3104A0630X	Assisted Living Facility (Behavioral Disturbances)

General Provider Information

NPI Number	:	1376296301
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PANACHE HOLISTICS

Provider Business Mailing Address
First Line	:	2552 BARCELONA AVE
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33905-2212
Country	:	US
Telephone Number	:	239-410-6250
Fax Number	:

Provider Business Practice Location Address
First Line	:	2552 BARCELONA AVE
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33905-2212
Country	:	US
Telephone Number	:	239-410-6250
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT, CEO
Name	:	MARY E PROVENCHER
Credential	:
Telephone Number	:	239-839-4997

Provider Enumeration Date	:	01/31/2022
Last Update Date	:	01/31/2022

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