Healthcare Provider Details

I. General information

NPI: 1790071322
Provider Name (Legal Business Name): FARREN C HOLMAN DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: FARREN C WISE DPT

II. Dates (important events)

Enumeration Date: 06/22/2011
Last Update Date: 07/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1832 WENTZVILLE PKWY
WENTZVILLE MO
63385-3817
US

IV. Provider business mailing address

4273 KEATON CROSSING BLVD
O FALLON MO
63368-8220
US

V. Phone/Fax

Practice location:
  • Phone: 636-327-7110
  • Fax:
Mailing address:
  • Phone: 636-206-4225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2011019601
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: