MEDICARE: TYRA R HOLLAND

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	347C00000X	Private Vehicle	347C00000X	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225759798
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYRA R HOLLAND

Provider Business Mailing Address
First Line	:	3339 WEST AVE
Second Line	:
City	:	BEAUMONT
State	:	TX
Zip	:	77703-3927
Country	:	US
Telephone Number	:	281-678-2006
Fax Number	:

Provider Business Practice Location Address
First Line	:	3339 WEST AVE
Second Line	:
City	:	BEAUMONT
State	:	TX
Zip	:	77703-3927
Country	:	US
Telephone Number	:	281-678-2006
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/02/2022
Last Update Date	:	09/02/2022

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Directions to “ TYRA R HOLLAND ” Practice Location

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