Healthcare Provider Details

I. General information

NPI: 1699775189
Provider Name (Legal Business Name): HOLLY HILL HOUSE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 04/19/2024
Certification Date: 04/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 KINGSTON RD
SULPHUR LA
70663-4016
US

IV. Provider business mailing address

100 KINGSTON RD
SULPHUR LA
70663-4016
US

V. Phone/Fax

Practice location:
  • Phone: 337-625-5843
  • Fax: 337-625-3432
Mailing address:
  • Phone: 337-625-5843
  • Fax: 337-625-3432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number198
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number198
License Number StateLA

VIII. Authorized Official

Name: JOSEPH C TUTERA
Title or Position: MANAGER
Credential:
Phone: 816-444-0900