1215211230 NPI number — MRS. CARISSA MARIE HOLSTED PTA

Table of content: MRS. CARISSA MARIE HOLSTED PTA (NPI 1215211230)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215211230 NPI number — MRS. CARISSA MARIE HOLSTED PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLSTED
Provider First Name:
CARISSA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PTA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1215211230
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1708
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLARKSTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48347-1708
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-922-9200
Provider Business Mailing Address Fax Number:
248-922-9700

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7508 M E CAD BLVD STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLARKSTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48348-4281
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-922-9200
Provider Business Practice Location Address Fax Number:
248-922-9700
Provider Enumeration Date:
10/10/2011

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: 225200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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