MEDICARE: HOLLY VISION SOURCE

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	152W00000X	Optometrist

General Provider Information

NPI Number	:	1881012011
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOLLY VISION SOURCE

Provider Business Mailing Address
First Line	:	1379 FLUSHING RD
Second Line	:
City	:	FLUSHING
State	:	MI
Zip	:	48433-2262
Country	:	US
Telephone Number	:	810-659-3135
Fax Number	:

Provider Business Practice Location Address
First Line	:	1121 N SAGINAW ST
Second Line	:	1
City	:	HOLLY
State	:	MI
Zip	:	48442-1380
Country	:	US
Telephone Number	:	810-659-3135
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MS. REBECCA WALLACE
Credential	:
Telephone Number	:	810-659-3135

Provider Enumeration Date	:	04/04/2014
Last Update Date	:	04/04/2014

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Directions to “HOLLY VISION SOURCE ” Practice Location

Language	Start Address	Practice Location

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