Healthcare Provider Details

I. General information

NPI: 1194453118
Provider Name (Legal Business Name): ETHAN HOLLAND PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2022
Last Update Date: 08/09/2022
Certification Date: 08/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 E ARLINGTON BLVD
GREENVILLE NC
27858-5868
US

IV. Provider business mailing address

916 TEAKWOOD DR
GREENVILLE NC
27834-0830
US

V. Phone/Fax

Practice location:
  • Phone: 252-565-8812
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberP21504
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: