Provider Demographics
NPI:1477610475
Name:HOLCOMB, RUSSELL DAVID (LCPO)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:DAVID
Last Name:HOLCOMB
Suffix:
Gender:M
Credentials:LCPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 HICKORY SPRINGS INDUSTRIAL DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-7933
Mailing Address - Country:US
Mailing Address - Phone:770-345-6899
Mailing Address - Fax:770-345-7341
Practice Address - Street 1:95 HICKORY SPRINGS IND DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-7933
Practice Address - Country:US
Practice Address - Phone:770-345-6899
Practice Address - Fax:770-345-7341
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Not Answered224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7700620Medicaid
GA0133300001Medicare ID - Type Unspecified