MEDICARE: MS. KIMBERLY ANNE HOLMAN MT

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	172V00000X	Community Health Worker	4760	OR

General Provider Information

NPI Number	:	1396912549
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KIMBERLY ANNE HOLMAN MT

Provider Business Mailing Address
First Line	:	PO BOX 3662
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97302-0662
Country	:	US
Telephone Number	:	503-391-2979
Fax Number	:	503-581-8389

Provider Business Practice Location Address
First Line	:	910 CAPITOL ST NE
Second Line	:	SUITE B
City	:	SALEM
State	:	OR
Zip	:	97301-1201
Country	:	US
Telephone Number	:	503-391-2979
Fax Number	:	503-581-8389

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

Provider Enumeration Date	:	05/15/2008
Last Update Date	:	05/15/2008

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