1609085455 NPI number — CRAIG D HOLMAN CHARTERED

Table of content: (NPI 1609085455)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609085455 NPI number — CRAIG D HOLMAN CHARTERED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRAIG D HOLMAN CHARTERED
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:
1609085455
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
496 SHOUP AVE W # B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TWIN FALLS
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83301-5043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-734-7676
Provider Business Mailing Address Fax Number:
208-736-8378

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
496 SHOUP AVE W # B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TWIN FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83301-5043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-734-7676
Provider Business Practice Location Address Fax Number:
208-736-8378
Provider Enumeration Date:
05/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HOLMAN
Authorized Official First Name:
CRAIG
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
208-734-7676

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  P119 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 185440600 . This is a "US DEPT OF LABOR" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 4134570001 . This is a "DMERC" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 480031477 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010152611 . This is a "REGENCE BLUE SHIELD OF ID" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: P9343 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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