Healthcare Provider Details

I. General information

NPI: 1841584240
Provider Name (Legal Business Name): DUSTY HOLLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2011
Last Update Date: 01/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

557 NW MONROE AVE
CORVALLIS OR
97330-4721
US

IV. Provider business mailing address

32554 BELLINGER SCALE RD
LEBANON OR
97355-9412
US

V. Phone/Fax

Practice location:
  • Phone: 541-766-3540
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: