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1093874364

NPI Code Detail

MEDICARE: JAVEN D. HOLM OD PA

MEDICARE: JAVEN D. HOLM OD PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	MN2192	MN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	C03824	OTHER	MN	MEDICARE GROUP #

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1285630632	OTHER	MN	JAVEN HOLM OD NPI
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	972N0FA	OTHER	MN	FEC GLASSES NUMBER
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	972N8FA	OTHER	MN	DR HOLM BCBS #

General Provider Information

NPI Number	:	1093874364
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JAVEN D. HOLM OD PA

Provider Business Mailing Address
First Line	:	1210 EAST BLUE EARTH AVENUE
Second Line	:
City	:	FAIRMONT
State	:	MN
Zip	:	56031-4441
Country	:	US
Telephone Number	:	507-238-3363
Fax Number	:

Provider Business Practice Location Address
First Line	:	1210 EAST BLUE EARTH AVENUE
Second Line	:
City	:	FAIRMONT
State	:	MN
Zip	:	56031-4441
Country	:	US
Telephone Number	:	507-238-3363
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JAVEN DELANO HOLM
Credential	:	OD
Telephone Number	:	507-238-3363

Provider Enumeration Date	:	12/06/2006
Last Update Date	:	12/14/2010

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Directions to “JAVEN D. HOLM OD PA ” Practice Location

Language	Start Address	Practice Location

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