1477275931 NPI number — MS. ELIZABETH ANN HOLDER ICADC

Table of content: MS. ELIZABETH ANN HOLDER ICADC (NPI 1477275931)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477275931 NPI number — MS. ELIZABETH ANN HOLDER ICADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLDER
Provider First Name:
ELIZABETH
Provider Middle Name:
ANN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
ICADC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HOLDER NIX
Provider Other First Name:
ELIZABETH
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
ICADC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1477275931
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
106 ROLLINGWOOD CIR NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROME
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30165-1732
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-767-3296
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
270 HERITAGE WALK
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODSTOCK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30188-3875
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-494-5700
Provider Business Practice Location Address Fax Number:
678-494-5703
Provider Enumeration Date:
09/13/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  829781 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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