Healthcare Provider Details

I. General information

NPI: 1942114806
Provider Name (Legal Business Name): HOLLY ADULT FAMILY HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7101 S HOLLY ST
CHENEY WA
99004-5376
US

IV. Provider business mailing address

7101 S HOLLY ST
CHENEY WA
99004-5376
US

V. Phone/Fax

Practice location:
  • Phone: 509-295-7501
  • Fax:
Mailing address:
  • Phone: 509-295-7501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number StateNULL

VIII. Authorized Official

Name: BRANDON ALLEN HUNT-LEWIS
Title or Position: OWNER
Credential: PROVIDER
Phone: 509-295-7501