Provider Demographics
NPI:1710976691
Name:HOLLER, MAX GARY (LAT)
Entity Type:Individual
Prefix:MR
First Name:MAX
Middle Name:GARY
Last Name:HOLLER
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1206 W 11TH ST
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:TX
Mailing Address - Zip Code:77541-5346
Mailing Address - Country:US
Mailing Address - Phone:979-230-0291
Mailing Address - Fax:
Practice Address - Street 1:1206 W 11TH ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:TX
Practice Address - Zip Code:77541-5346
Practice Address - Country:US
Practice Address - Phone:979-230-0291
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX07472255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer