Provider Demographics
NPI:1801862750
Name:HOLLADAY MEDICORP, INC.
Entity Type:Organization
Organization Name:HOLLADAY MEDICORP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:NICK
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLEDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-679-8852
Mailing Address - Street 1:2551 LANDMARK DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6717
Mailing Address - Country:US
Mailing Address - Phone:336-760-2111
Mailing Address - Fax:336-768-7731
Practice Address - Street 1:2551 LANDMARK DR
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6717
Practice Address - Country:US
Practice Address - Phone:336-760-2111
Practice Address - Fax:336-768-7731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7700359Medicaid