Healthcare Provider Details

I. General information

NPI: 1780698258
Provider Name (Legal Business Name): THOMAS L HOLT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SINGLETON RIDGE RD
CONWAY SC
29526-9142
US

IV. Provider business mailing address

PO BOX 829
CONWAY SC
29528-0829
US

V. Phone/Fax

Practice location:
  • Phone: 843-347-8037
  • Fax: 843-347-8056
Mailing address:
  • Phone: 843-347-8037
  • Fax: 843-347-8056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR89446
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: