MEDICARE: MR. KEORRIC LAMONT HOLIDAY

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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	14557506	TX

General Provider Information

NPI Number	:	1568608420
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KEORRIC LAMONT HOLIDAY

Provider Business Mailing Address
First Line	:	3705 FORT HUNT DRIVE
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76016
Country	:	US
Telephone Number	:	817-919-7013
Fax Number	:	682-587-4118

Provider Business Practice Location Address
First Line	:	3705 FORT HUNT DRIVE
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76016
Country	:	US
Telephone Number	:	817-919-7013
Fax Number	:	682-587-4118

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

Provider Enumeration Date	:	12/26/2008
Last Update Date	:	12/26/2008

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