Provider Demographics
NPI:1083179105
Name:HOLT, MICHAEL EROOL I
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EROOL
Last Name:HOLT
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4289 E OCEAN BLVD
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-2996
Mailing Address - Country:US
Mailing Address - Phone:562-714-4270
Mailing Address - Fax:
Practice Address - Street 1:4289 E OCEAN BLVD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90803-2996
Practice Address - Country:US
Practice Address - Phone:562-714-4270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-02
Last Update Date:2019-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60738225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist