1750795787 NPI number — HOLLY NICHOLE MUNSON D.O.

Table of content: HOLLY NICHOLE MUNSON D.O. (NPI 1750795787)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750795787 NPI number — HOLLY NICHOLE MUNSON D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MUNSON
Provider First Name:
HOLLY
Provider Middle Name:
NICHOLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1750795787
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/16/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 E MCBEE AVE FL 4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29601-2842
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-522-8603
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
103 WHITETAIL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALHALLA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29691-5837
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-638-3444
Provider Business Practice Location Address Fax Number:
864-638-3445
Provider Enumeration Date:
06/18/2014

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: 207Q00000X , with the licence number:  LL36722 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 36722 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: SCA980 . This is a "MEDICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 367222 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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