Provider Demographics
NPI:1851945513
Name:GHOLSTON, LANCE
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:
Last Name:GHOLSTON
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 1:301 W WARRIOR TRL
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-5718
Mailing Address - Country:US
Mailing Address - Phone:972-343-1676
Mailing Address - Fax:972-343-1515
Practice Address - Street 1:301 W WARRIOR TRL
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-5718
Practice Address - Country:US
Practice Address - Phone:972-343-1676
Practice Address - Fax:972-343-1515
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT40612255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer