Healthcare Provider Details

I. General information

NPI: 1104277698
Provider Name (Legal Business Name): LAURA LYNN HOLSHOUSER DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA LYNN KIGHT DPT

II. Dates (important events)

Enumeration Date: 06/25/2016
Last Update Date: 04/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1706 MAGNOLIA WAY
AUGUSTA GA
30909-9481
US

IV. Provider business mailing address

1706 MAGNOLIA WAY
AUGUSTA GA
30909-9481
US

V. Phone/Fax

Practice location:
  • Phone: 706-210-7529
  • Fax: 706-312-7610
Mailing address:
  • Phone: 706-210-7529
  • Fax: 706-312-7610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT012362
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: