=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437738044
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOLMAN RECOVERY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2021
-----------------------------------------------------
Last Update Date | 04/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16415 SMOKEY POINT BLVD
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-630-1447
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 215 266TH PL NE
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98223-7439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-630-1447
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BOARD PRESIDENT
-----------------------------------------------------
Name | MR. EDMUND HARRY SMITH
-----------------------------------------------------
Credential | BA, SUDP
-----------------------------------------------------
Telephone | 360-630-1447
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------