Provider Demographics
NPI:1669091179
Name:HOLLISTER, VIVIAN ELAINE
Entity type:Individual
Prefix:MRS
First Name:VIVIAN
Middle Name:ELAINE
Last Name:HOLLISTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1579 LCR 310
Mailing Address - Street 2:
Mailing Address - City:MART, TEXAS
Mailing Address - State:TX
Mailing Address - Zip Code:76664-5206
Mailing Address - Country:US
Mailing Address - Phone:254-344-2217
Mailing Address - Fax:254-344-2217
Practice Address - Street 1:1579 LCR 310
Practice Address - Street 2:
Practice Address - City:MART, TEXAS
Practice Address - State:TX
Practice Address - Zip Code:76664-5206
Practice Address - Country:US
Practice Address - Phone:254-344-2217
Practice Address - Fax:254-344-2217
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-14
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000422310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility