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General NPI Number Information
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NPI Number | 1386434041
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Entity Type | Organization
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Legal Business Name | HOLON HEALTH GREAT LAKES, P.C.
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Dates
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Enumeration Date | 05/07/2025
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Last Update Date | 05/07/2025
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Provider Practice Location Address
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Address Line | 3341 N 19TH AVE
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City | PHOENIX
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State | AZ
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Zip | 85015-5702
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Country | US
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Telephone | 877-465-6650
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Fax | 804-294-2775
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Provider Business Mailing Address
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Address Line | 3540 PUMP RD # 1188
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City | RICHMOND
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State | VA
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Zip | 23233-1115
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Country | US
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Telephone | 804-955-5246
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Fax | 804-294-2775
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Authorized Official
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Title or Position | CEO
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Name | JASON HERZOG
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Credential |
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Telephone | 804-955-5246
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number |
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License Number State |
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