Healthcare Provider Details

I. General information

NPI: 1952301053
Provider Name (Legal Business Name): JOHN L HOLCOMB OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 03/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 OKLAHOMA AVE
TRENTON MO
64683-2559
US

IV. Provider business mailing address

PO BOX 339
TRENTON MO
64683-0339
US

V. Phone/Fax

Practice location:
  • Phone: 660-359-2204
  • Fax: 660-359-4804
Mailing address:
  • Phone: 660-359-2204
  • Fax: 660-359-4804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2175
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: