Provider Demographics
NPI:1467571232
Name:HOLLIDAY, MITCHEL KIRK (RD)
Entity Type:Individual
Prefix:
First Name:MITCHEL
Middle Name:KIRK
Last Name:HOLLIDAY
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 860
Mailing Address - Street 2:
Mailing Address - City:WHITERIVER
Mailing Address - State:AZ
Mailing Address - Zip Code:85941-0860
Mailing Address - Country:US
Mailing Address - Phone:928-338-3574
Mailing Address - Fax:928-338-3522
Practice Address - Street 1:200 WEST HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:WHITERIVER
Practice Address - State:AZ
Practice Address - Zip Code:85941-0860
Practice Address - Country:US
Practice Address - Phone:928-338-3574
Practice Address - Fax:928-338-3522
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
953262133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered