MEDICARE: MR. BRAD K HOLMGREN LISW

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	1041C0700X	Clinical Social Worker	I3761	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699804286
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRAD K HOLMGREN LISW

Provider Business Mailing Address
First Line	:	226 N. CALIFORNIA AVE
Second Line	:
City	:	SILVER CITY
State	:	NM
Zip	:	88061
Country	:	US
Telephone Number	:	505-388-0263
Fax Number	:

Provider Business Practice Location Address
First Line	:	900 CENTRAL
Second Line	:
City	:	BAYARD
State	:	NM
Zip	:	88023
Country	:	US
Telephone Number	:	505-537-4000
Fax Number	:	505-537-3358

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

Provider Enumeration Date	:	03/02/2007
Last Update Date	:	07/08/2007

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