Provider Demographics
NPI:1841584240
Name:HOLLER, DUSTY
Entity Type:Individual
Prefix:
First Name:DUSTY
Middle Name:
Last Name:HOLLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32554 BELLINGER SCALE RD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-9412
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:557 NW MONROE AVE
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-4721
Practice Address - Country:US
Practice Address - Phone:541-766-3540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-02
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider