1164936787 NPI number — MARVIN L. HOLLOMAN

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164936787 NPI number — MARVIN L. HOLLOMAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARVIN L. HOLLOMAN
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164936787
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/17/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21706 PETERSON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAUK VILLAGE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60411-4438
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
425 JOLIET ST STE 125
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DYER
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46311-1775
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-625-5681
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/17/2017

Additional Information

Authorized Official

Authorized Official Last Name:
HOLLOMAN
Authorized Official First Name:
LATOYA
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMIN
Authorized Official Telephone Number:
708-625-5681

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  69000690A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 69000690A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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