MEDICARE: HOLON HEALTH GREAT LAKES, P.C.

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	261QC1500X	Community Health Clinic/Center

General Provider Information

NPI Number	:	1740084896
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOLON HEALTH GREAT LAKES, P.C.

Provider Business Mailing Address
First Line	:	3540 PUMP RD # 1188
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23233-1115
Country	:	US
Telephone Number	:	804-955-5246
Fax Number	:

Provider Business Practice Location Address
First Line	:	5650 S 12TH AVE STE 132
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85706-3187
Country	:	US
Telephone Number	:	877-465-6650
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	JASON HERZOG
Credential	:
Telephone Number	:	804-955-5246

Provider Enumeration Date	:	04/01/2025
Last Update Date	:	04/01/2025

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Directions to “HOLON HEALTH GREAT LAKES, P.C. ” Practice Location

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