Healthcare Provider Details

I. General information

NPI: 1760965842
Provider Name (Legal Business Name): HOLLY VALLE LSA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2018
Last Update Date: 11/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4780 N JOSEY LN
CARROLLTON TX
75010-4615
US

IV. Provider business mailing address

2304 CORTELLIA ST
PLANO TX
75074-0296
US

V. Phone/Fax

Practice location:
  • Phone: 972-395-2210
  • Fax:
Mailing address:
  • Phone: 940-395-6484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License NumberSA00777
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: