MEDICARE: MR. MAX GARY HOLLER L.A.T.

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	2255A2300X	Athletic Trainer	0747	TX

General Provider Information

NPI Number	:	1710976691
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MAX GARY HOLLER L.A.T.

Provider Business Mailing Address
First Line	:	1206 W 11TH ST
Second Line	:
City	:	FREEPORT
State	:	TX
Zip	:	77541-5346
Country	:	US
Telephone Number	:	979-230-0291
Fax Number	:

Provider Business Practice Location Address
First Line	:	1206 W 11TH ST
Second Line	:
City	:	FREEPORT
State	:	TX
Zip	:	77541-5346
Country	:	US
Telephone Number	:	979-230-0291
Fax Number	:

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

Provider Enumeration Date	:	10/14/2005
Last Update Date	:	07/08/2007

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