MEDICARE: LEROY KENNETH HOLLEY LPN

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	164W00000X	Licensed Practical Nurse	PN0330637	CO

General Provider Information

NPI Number	:	1417380932
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEROY KENNETH HOLLEY LPN

Provider Business Mailing Address
First Line	:	324 N ASH ST
Second Line	:
City	:	CORTEZ
State	:	CO
Zip	:	81321-2812
Country	:	US
Telephone Number	:	970-564-0152
Fax Number	:

Provider Business Practice Location Address
First Line	:	324 N ASH ST
Second Line	:
City	:	CORTEZ
State	:	CO
Zip	:	81321-2812
Country	:	US
Telephone Number	:	970-564-0152
Fax Number	:

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

Provider Enumeration Date	:	08/20/2013
Last Update Date	:	08/20/2013

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