Healthcare Provider Details

I. General information

NPI: 1598418253
Provider Name (Legal Business Name): MR. JUSTIN DION HOLLIDAY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2022
Last Update Date: 03/25/2024
Certification Date: 03/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 E 3RD ST
NEW YORK NY
10003-8908
US

IV. Provider business mailing address

200 VARICK ST FL 9
NEW YORK NY
10014-4810
US

V. Phone/Fax

Practice location:
  • Phone: 212-533-8400
  • Fax: 212-533-8403
Mailing address:
  • Phone: 212-620-0340
  • Fax: 212-533-8403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number073183
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: