Healthcare Provider Details

I. General information

NPI: 1154420164
Provider Name (Legal Business Name): THOMAS WAYNE HOLTON M.S.S. A.T.,C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83 WINDHAM ST
WILLIMANTIC CT
06226-2211
US

IV. Provider business mailing address

77 DEER RUN RD
WINDHAM CT
06280-1535
US

V. Phone/Fax

Practice location:
  • Phone: 860-465-5171
  • Fax: 860-465-4696
Mailing address:
  • Phone: 860-450-0893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number255A2300X
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: