=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366901399
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HOLLY MAE IVES
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2019
-----------------------------------------------------
Last Update Date | 03/19/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 509 UNIVERSITY DRIVE
-----------------------------------------------------
City | EAU CLAIRE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54701-5470
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 785-806-5556
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2435 SE TECUMSEH RD
-----------------------------------------------------
City | TECUMSEH
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66542-9327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 785-806-5556
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------