Provider Demographics
NPI:1790071322
Name:HOLMAN, FARREN C (DPT)
Entity Type:Individual
Prefix:
First Name:FARREN
Middle Name:C
Last Name:HOLMAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:FARREN
Other - Middle Name:C
Other - Last Name:WISE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:4273 KEATON CROSSING BLVD
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-8220
Mailing Address - Country:US
Mailing Address - Phone:636-206-4225
Mailing Address - Fax:
Practice Address - Street 1:1832 WENTZVILLE PKWY
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-3817
Practice Address - Country:US
Practice Address - Phone:636-327-7110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2019-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011019601225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO991509011Medicare PIN