=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538499611
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HOLLY LYNN MCCLINTOCK LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2010
-----------------------------------------------------
Last Update Date | 01/12/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 85 W. MILL STREET
-----------------------------------------------------
City | BAYFIELD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-884-8900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 82 DEER RIDGE DR
-----------------------------------------------------
City | BAYFIELD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81122-9418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-769-5319
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 3591
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------