Provider Demographics
NPI:1023330370
Name:C. JUSTIN HOLCOMB, OD, LLC
Entity type:Organization
Organization Name:C. JUSTIN HOLCOMB, OD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:JUSTIN
Authorized Official - Last Name:HOLCOMB
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:305-785-1886
Mailing Address - Street 1:16750 NW 21ST ST
Mailing Address - Street 2:206
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-1869
Mailing Address - Country:US
Mailing Address - Phone:305-785-1886
Mailing Address - Fax:
Practice Address - Street 1:10315 SILVERDALE WAY NW
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-7670
Practice Address - Country:US
Practice Address - Phone:360-698-0284
Practice Address - Fax:360-698-0284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-26
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60102641305S00000X, 305R00000X
FLOPC4902305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
No305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013564100Medicaid