MEDICARE: DR. GREGORY VERNON HOLLSTROM DC

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	111N00000X	Chiropractor	CH002658	FL

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	:	1710988811
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGORY VERNON HOLLSTROM DC

Provider Business Mailing Address
First Line	:	11444 SEMINOLE BLVD
Second Line	:
City	:	LARGO
State	:	FL
Zip	:	33778-3237
Country	:	US
Telephone Number	:	727-393-6100
Fax Number	:	727-393-5461

Provider Business Practice Location Address
First Line	:	11444 SEMINOLE BLVD
Second Line	:
City	:	LARGO
State	:	FL
Zip	:	33778-3237
Country	:	US
Telephone Number	:	727-393-6100
Fax Number	:	727-393-5461

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

Provider Enumeration Date	:	08/10/2005
Last Update Date	:	08/23/2010

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