1467687624 NPI number — STACI STEWART HOLLOWAY MPT

Table of content: STACI STEWART HOLLOWAY MPT (NPI 1467687624)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467687624 NPI number — STACI STEWART HOLLOWAY MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLLOWAY
Provider First Name:
STACI
Provider Middle Name:
STEWART
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:
GRAHAM
Provider Other First Name:
STACI
Provider Other Middle Name:
STEWART
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1467687624
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
363 S DOS CAMINOS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VENTURA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93003-4734
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-654-8544
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2895 LOMA VISTA RD
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
VENTURA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93003-1572
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-643-4093
Provider Business Practice Location Address Fax Number:
805-643-8401
Provider Enumeration Date:
05/18/2009

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:  PT 21756 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 056608 . This is a "MEDICARE PROVIDER ID" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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