1265568356 NPI number — HOLLY E ACREE MPT

Table of content: HOLLY E ACREE MPT (NPI 1265568356)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265568356 NPI number — HOLLY E ACREE MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ACREE
Provider First Name:
HOLLY
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NEALON
Provider Other First Name:
HOLLY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1265568356
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
230 CLEARFIELD AVE
Provider Second Line Business Mailing Address:
SUITE 124
Provider Business Mailing Address City Name:
VIRGINIA BEACH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23462-1832
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-321-3300
Provider Business Mailing Address Fax Number:
757-321-3332

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1975 GLEN MITCHELL DRIVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
VA BEACH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23456
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-321-3300
Provider Business Practice Location Address Fax Number:
757-321-3332
Provider Enumeration Date:
02/26/2007

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: 225100000X , with the licence number:  2305203740 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 010410436 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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