Provider Demographics
NPI:1912990714
Name:HOLLOWAY, KENNY (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNY
Middle Name:
Last Name:HOLLOWAY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 N MAIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:GA
Mailing Address - Zip Code:30143-1557
Mailing Address - Country:US
Mailing Address - Phone:706-692-5633
Mailing Address - Fax:706-692-0027
Practice Address - Street 1:105 N MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143-1557
Practice Address - Country:US
Practice Address - Phone:706-692-5633
Practice Address - Fax:706-692-0027
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002252152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist