Healthcare Provider Details

I. General information

NPI: 1306765961
Provider Name (Legal Business Name): HOLLIS LADSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

248 LUZ DR
GEORGETOWN SC
29440-9036
US

IV. Provider business mailing address

248 LUZ DR
GEORGETOWN SC
29440-9036
US

V. Phone/Fax

Practice location:
  • Phone: 813-590-9880
  • Fax:
Mailing address:
  • Phone: 813-590-9880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number106197389
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: