=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740073782
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOLON HEALTH GREAT LAKES, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2025
-----------------------------------------------------
Last Update Date | 05/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2364 KINGMAN AVE
-----------------------------------------------------
City | KINGMAN
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86401-4840
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-754-4694
-----------------------------------------------------
Fax | 804-294-2775
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3540 PUMP RD # 1188
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23233-1115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-754-4694
-----------------------------------------------------
Fax | 804-294-2775
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JASON HERZOG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 804-955-5246
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 175T00000X
-----------------------------------------------------
Taxonomy Name | Peer Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------