Healthcare Provider Details

I. General information

NPI: 1386434041
Provider Name (Legal Business Name): HOLON HEALTH GREAT LAKES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2025
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3341 N 19TH AVE
PHOENIX AZ
85015-5702
US

IV. Provider business mailing address

3540 PUMP RD # 1188
RICHMOND VA
23233-1115
US

V. Phone/Fax

Practice location:
  • Phone: 877-465-6650
  • Fax: 804-294-2775
Mailing address:
  • Phone: 804-955-5246
  • Fax: 804-294-2775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name: JASON HERZOG
Title or Position: CEO
Credential:
Phone: 804-955-5246