Provider Demographics
NPI:1790237345
Name:HOLLANDALE FAMILY CARE
Entity Type:Organization
Organization Name:HOLLANDALE FAMILY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCGAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-335-0183
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:HOLLANDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38748-0247
Mailing Address - Country:US
Mailing Address - Phone:662-827-2214
Mailing Address - Fax:
Practice Address - Street 1:1257 HIGHWAY 61 S
Practice Address - Street 2:
Practice Address - City:HOLLANDALE
Practice Address - State:MS
Practice Address - Zip Code:38748-3864
Practice Address - Country:US
Practice Address - Phone:662-827-2214
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DELTA HEART AND VASCULAR
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-31
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901794363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty