Healthcare Provider Details

I. General information

NPI: 1336783034
Provider Name (Legal Business Name): DUSTIN L HOLSTON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2019
Last Update Date: 11/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 STEWART ACRES
WINFIELD WV
25213-9716
US

IV. Provider business mailing address

213 STEWART ACRES
WINFIELD WV
25213-9716
US

V. Phone/Fax

Practice location:
  • Phone: 304-951-7030
  • Fax:
Mailing address:
  • Phone: 304-951-7030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: