Provider Demographics
NPI:1780252627
Name:HOLDER, MAMATA
Entity type:Individual
Prefix:
First Name:MAMATA
Middle Name:
Last Name:HOLDER
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 1:1205 E 22ND ST APT 708
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95901-3612
Mailing Address - Country:US
Mailing Address - Phone:530-812-7946
Mailing Address - Fax:
Practice Address - Street 1:2804 ROMER BLVD
Practice Address - Street 2:
Practice Address - City:POLLOCK PINES
Practice Address - State:CA
Practice Address - Zip Code:95726-9242
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other