Healthcare Provider Details

I. General information

NPI: 1851832729
Provider Name (Legal Business Name): ENETRA HOLMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2017
Last Update Date: 03/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MARTIN DR
BIRMINGHAM AL
35215-1109
US

IV. Provider business mailing address

100 MARTIN DR
BIRMINGHAM AL
35215-1109
US

V. Phone/Fax

Practice location:
  • Phone: 205-601-1075
  • Fax:
Mailing address:
  • Phone: 205-601-1075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number126097
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: