MEDICARE: HOLISTIC GYNECOLOGY, INC

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	174400000X	Specialist	033289	GA

General Provider Information

NPI Number	:	1700971504
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOLISTIC GYNECOLOGY, INC

Provider Business Mailing Address
First Line	:	1681 FRAZIER PARK DR.
Second Line	:	DECATUR
City	:	DECATUR
State	:	GA
Zip	:	30033-0398
Country	:	US
Telephone Number	:	404-216-4581
Fax Number	:	678-205-0416

Provider Business Practice Location Address
First Line	:	2785 LAWRENCEVILLE HWY
Second Line	:	SUITE 107
City	:	DECATUR
State	:	GA
Zip	:	30033-2515
Country	:	US
Telephone Number	:	678-205-0405
Fax Number	:	678-205-0416

Authorized Official
Title or Position	:	OWNER
Name	:	JUAQUITA D CALLAWAY
Credential	:	MD
Telephone Number	:	678-205-0405

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	04/28/2020

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