Healthcare Provider Details

I. General information

NPI: 1740459718
Provider Name (Legal Business Name): KEVIN EUGENE HOLLIS CMA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2008
Last Update Date: 02/13/2024
Certification Date: 02/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12612 CHALLENGER PKWY STE 365
ORLANDO FL
32826-2784
US

IV. Provider business mailing address

212 N 1ST ST NE
CLAY CITY IL
62824-1012
US

V. Phone/Fax

Practice location:
  • Phone: 407-306-8441
  • Fax:
Mailing address:
  • Phone: 618-317-0472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: