Healthcare Provider Details

I. General information

NPI: 1790168763
Provider Name (Legal Business Name): HOLLON LIVERMORE RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2015
Last Update Date: 03/07/2023
Certification Date: 03/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 BELLWETHER WAY STE 223
BELLINGHAM WA
98225-2914
US

IV. Provider business mailing address

776 CORDOVA AVE
ORMOND BEACH FL
32174-7638
US

V. Phone/Fax

Practice location:
  • Phone: 360-230-8202
  • Fax:
Mailing address:
  • Phone: 850-776-2410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberRPT42082
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND9815
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: