Provider Demographics
NPI:1740240522
Name:MT HOLLY FAMILY PRACTICE INC
Entity Type:Organization
Organization Name:MT HOLLY FAMILY PRACTICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-822-6200
Mailing Address - Street 1:PO BOX 786
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOLLY
Mailing Address - State:NC
Mailing Address - Zip Code:28120
Mailing Address - Country:US
Mailing Address - Phone:704-822-6200
Mailing Address - Fax:704-822-1601
Practice Address - Street 1:305 W CATAWBA AVE
Practice Address - Street 2:
Practice Address - City:MOUNT HOLLY
Practice Address - State:NC
Practice Address - Zip Code:28120-1613
Practice Address - Country:US
Practice Address - Phone:704-822-6200
Practice Address - Fax:704-822-1601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-24
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC897813AMedicaid
NC5950360Medicaid
NC897813AMedicaid