MEDICARE: HOLLIS AK LLC

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	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1295454650
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOLLIS AK LLC

Provider Business Mailing Address
First Line	:	19002 JAMAICA AVE
Second Line	:
City	:	JAMAICA
State	:	NY
Zip	:	11423-2034
Country	:	US
Telephone Number	:	718-577-2211
Fax Number	:	929-399-7959

Provider Business Practice Location Address
First Line	:	19002 JAMAICA AVE
Second Line	:
City	:	JAMAICA
State	:	NY
Zip	:	11423-2034
Country	:	US
Telephone Number	:	718-577-2211
Fax Number	:	929-399-7959

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ARI KALONTAROV
Credential	:
Telephone Number	:	347-245-2279

Provider Enumeration Date	:	08/26/2022
Last Update Date	:	11/06/2023

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Directions to “HOLLIS AK LLC ” Practice Location

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