Healthcare Provider Details

I. General information

NPI: 1053189803
Provider Name (Legal Business Name): PAUL KEITH HOLLAND
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2023
Last Update Date: 05/21/2024
Certification Date: 05/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

341 OFFICE PARK DR
COLUMBIA KY
42728-1392
US

IV. Provider business mailing address

341 OFFICE PARK DR
COLUMBIA KY
42728-1392
US

V. Phone/Fax

Practice location:
  • Phone: 270-380-1601
  • Fax:
Mailing address:
  • Phone: 270-380-1601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: