Provider Demographics
NPI:1518471986
Name:HOLT, TYRIN W
Entity Type:Individual
Prefix:
First Name:TYRIN
Middle Name:W
Last Name:HOLT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BROOKE HAVEN
Other - Middle Name:
Other - Last Name:CARE HOME
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BHCH
Mailing Address - Street 1:4009 COTTAGE PARK CT
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76013-8087
Mailing Address - Country:US
Mailing Address - Phone:817-308-1806
Mailing Address - Fax:
Practice Address - Street 1:1540 BERCKMANS RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76120-1500
Practice Address - Country:US
Practice Address - Phone:817-308-1806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-21
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX823477505174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist