Provider Demographics
NPI:1336783034
Name:HOLSTON, DUSTIN L
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:L
Last Name:HOLSTON
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 1:213 STEWART ACRES
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:25213-9716
Mailing Address - Country:US
Mailing Address - Phone:304-951-7030
Mailing Address - Fax:
Practice Address - Street 1:213 STEWART ACRES
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:WV
Practice Address - Zip Code:25213-9716
Practice Address - Country:US
Practice Address - Phone:304-951-7030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-05
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionist