Provider Demographics
NPI:1669118964
Name:HOLKO, BENJAMIN ROBERT
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:ROBERT
Last Name:HOLKO
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 1:14 E LA DIOSA DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-2159
Mailing Address - Country:US
Mailing Address - Phone:480-440-1419
Mailing Address - Fax:
Practice Address - Street 1:14 E LA DIOSA DR
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-2159
Practice Address - Country:US
Practice Address - Phone:480-440-1419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-09
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-24825225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty