Provider Demographics
NPI:1558121640
Name:HOLT, FARREL LEE (LDO, NCLEC, ABOC)
Entity Type:Individual
Prefix:
First Name:FARREL
Middle Name:LEE
Last Name:HOLT
Suffix:
Gender:M
Credentials:LDO, NCLEC, ABOC
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 402
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31202-0402
Mailing Address - Country:US
Mailing Address - Phone:478-318-8922
Mailing Address - Fax:
Practice Address - Street 1:1401 GRAY HWY
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31211-1905
Practice Address - Country:US
Practice Address - Phone:478-755-1295
Practice Address - Fax:478-755-9876
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2038156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty