Healthcare Provider Details

I. General information

NPI: 1821942194
Provider Name (Legal Business Name): KAYLA HOLOVACH
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2026
Last Update Date: 02/24/2026
Certification Date: 02/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1589 VALLE DE COLORES ST NW
LOS LUNAS NM
87031-9158
US

IV. Provider business mailing address

1589 VALLE DE COLORES ST NW
LOS LUNAS NM
87031-9158
US

V. Phone/Fax

Practice location:
  • Phone: 505-259-2657
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License NumberPT-2023-2065
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: