MEDICARE: IVORY HOLLAMON

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	374U00000X	Home Health Aide

General Provider Information

NPI Number	:	1952790594
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IVORY HOLLAMON

Provider Business Mailing Address
First Line	:	318 CHICAGO PL NW
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44703-1726
Country	:	US
Telephone Number	:	614-815-8914
Fax Number	:

Provider Business Practice Location Address
First Line	:	1209 LIPPERT RD NE
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44705-1019
Country	:	US
Telephone Number	:	937-889-8000
Fax Number	:

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

Provider Enumeration Date	:	01/20/2015
Last Update Date	:	03/14/2018

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Directions to “ IVORY HOLLAMON ” Practice Location

Language	Start Address	Practice Location

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