MEDICARE: HOLLY SERVICES, INC.

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	261QA0600X	Adult Day Care Clinic/Center
2	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1609635820
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOLLY SERVICES, INC.

Provider Business Mailing Address
First Line	:	PO BOX 1521
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96806-1521
Country	:	US
Telephone Number	:	626-333-6767
Fax Number	:

Provider Business Practice Location Address
First Line	:	11100 VALLEY BLVD STE 340
Second Line	:
City	:	EL MONTE
State	:	CA
Zip	:	91731-2509
Country	:	US
Telephone Number	:	626-333-6767
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. KAN KOSUGI
Credential	:
Telephone Number	:	626-333-6767

Provider Enumeration Date	:	03/18/2024
Last Update Date	:	12/23/2025

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Directions to “HOLLY SERVICES, INC. ” Practice Location

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