Healthcare Provider Details

I. General information

NPI: 1407301070
Provider Name (Legal Business Name): KATIE HOLLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2016
Last Update Date: 08/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20072 SW BIRCH ST STE 190
NEWPORT BEACH CA
92660-0799
US

IV. Provider business mailing address

851 DOMINGO DR APT 24
NEWPORT BEACH CA
92660-4578
US

V. Phone/Fax

Practice location:
  • Phone: 949-673-8088
  • Fax:
Mailing address:
  • Phone: 949-274-0248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number18516
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: