Provider Demographics
NPI:1740797901
Name:HOLM, OLAF M (LPO)
Entity Type:Individual
Prefix:
First Name:OLAF
Middle Name:M
Last Name:HOLM
Suffix:
Gender:M
Credentials:LPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 W MLK BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-3338
Mailing Address - Country:US
Mailing Address - Phone:813-224-0525
Mailing Address - Fax:813-224-0622
Practice Address - Street 1:812 W MLK BLVD STE 100
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-3338
Practice Address - Country:US
Practice Address - Phone:813-224-0525
Practice Address - Fax:813-224-0622
Is Sole Proprietor?:No
Enumeration Date:2018-01-09
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPOR124222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005843900Medicaid