1699775189 NPI number — HOLLY HILL HOUSE, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699775189 NPI number — HOLLY HILL HOUSE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOLLY HILL HOUSE, LLC
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:
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:
1699775189
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 KINGSTON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SULPHUR
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70663-4016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-625-5843
Provider Business Mailing Address Fax Number:
337-625-3432

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 KINGSTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SULPHUR
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70663-4016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-625-5843
Provider Business Practice Location Address Fax Number:
337-625-3432
Provider Enumeration Date:
07/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
TUTERA
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
C
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
816-444-0900

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  198 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 335E00000X , with the licence number: 198 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1517038 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2026 www.npivalidator.com