Provider Demographics
NPI:1164936787
Name:MARVIN L. HOLLOMAN
Entity Type:Organization
Organization Name:MARVIN L. HOLLOMAN
Other - Org Name:M & L MEDICAL SUPPLIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:MRS
Authorized Official - First Name:LATOYA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLOMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-625-5681
Mailing Address - Street 1:21706 PETERSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAUK VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60411-4438
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:425 JOLIET ST STE 125
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-1775
Practice Address - Country:US
Practice Address - Phone:708-625-5681
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-17
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN69000690A332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN69000690AMedicaid