Provider Demographics
NPI:1225690845
Name:HOLLOWAY, JAVON
Entity Type:Individual
Prefix:
First Name:JAVON
Middle Name:
Last Name:HOLLOWAY
Suffix:
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 1:696 AYLESBURY DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-7182
Mailing Address - Country:US
Mailing Address - Phone:757-439-2028
Mailing Address - Fax:
Practice Address - Street 1:696 AYLESBURY DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-7182
Practice Address - Country:US
Practice Address - Phone:757-439-2028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-03
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT60568686172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver