=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295052454
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOLT CHIROPRACTIC & MASSAGE PS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2010
-----------------------------------------------------
Last Update Date | 08/23/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1800 SE MILE HILL DR SUITE 150
-----------------------------------------------------
City | PORT ORCHARD
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98366-3511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-874-0232
-----------------------------------------------------
Fax | 360-874-0658
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1800 SE MILE HILL DR SUITE 150
-----------------------------------------------------
City | PORT ORCHARD
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98366-3511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-874-0232
-----------------------------------------------------
Fax | 360-874-0658
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. THOMAS W HOLT
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 360-874-0232
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MA00015920
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MA 60074093
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH 00003171
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------