Provider Demographics
NPI:1376504035
Name:MARILYN HOLM
Entity Type:Organization
Organization Name:MARILYN HOLM
Other - Org Name:HOLM VISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:HOLM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:316-209-0142
Mailing Address - Street 1:1320 S COUNTRYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99623-9228
Mailing Address - Country:US
Mailing Address - Phone:316-209-0142
Mailing Address - Fax:
Practice Address - Street 1:1320 S COUNTRYWOOD DR
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99623-9228
Practice Address - Country:US
Practice Address - Phone:316-209-0142
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-31
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1550152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS13089OtherPHS
KS100346290DMedicaid
KS2062367OtherFIRST HEALTH
KS39850OtherFIRSTGUARD
KS13089OtherPHS
KS100346290DMedicaid