Provider Demographics
NPI:1881012011
Name:HOLLY VISION SOURCE
Entity Type:Organization
Organization Name:HOLLY VISION SOURCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-659-3135
Mailing Address - Street 1:1379 FLUSHING RD
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:MI
Mailing Address - Zip Code:48433-2262
Mailing Address - Country:US
Mailing Address - Phone:810-659-3135
Mailing Address - Fax:
Practice Address - Street 1:1121 N SAGINAW ST
Practice Address - Street 2:1
Practice Address - City:HOLLY
Practice Address - State:MI
Practice Address - Zip Code:48442-1380
Practice Address - Country:US
Practice Address - Phone:810-659-3135
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLUSHING VISION CLINIC, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-04
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty