Provider Demographics
NPI:1619338332
Name:HOLLOWAY, BRADLY
Entity Type:Individual
Prefix:
First Name:BRADLY
Middle Name:
Last Name:HOLLOWAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 W SPENCER CT
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60067-2206
Mailing Address - Country:US
Mailing Address - Phone:847-452-5710
Mailing Address - Fax:
Practice Address - Street 1:965 W SPENCER CT
Practice Address - Street 2:
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60067-2206
Practice Address - Country:US
Practice Address - Phone:847-452-5710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-08
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL81-1715543332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies