MEDICARE: DAMEKA HOLSTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1194145508
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAMEKA HOLSTON

Provider Business Mailing Address
First Line	:	5632 SAINT MARYS RD APT 1A
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31907-6948
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5632 SAINT MARYS RD APT 1A
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31907-6948
Country	:	US
Telephone Number	:	706-566-6404
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/24/2014
Last Update Date	:	04/24/2014

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Directions to “ DAMEKA HOLSTON ” Practice Location

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