Provider Demographics
NPI:1063596518
Name:S. KEITH HOLTON, PLLC
Entity type:Organization
Organization Name:S. KEITH HOLTON, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-243-1097
Mailing Address - Street 1:2205 5TH ST N
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-2211
Mailing Address - Country:US
Mailing Address - Phone:662-243-1097
Mailing Address - Fax:662-243-1095
Practice Address - Street 1:2205 5TH ST N
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2211
Practice Address - Country:US
Practice Address - Phone:662-243-1097
Practice Address - Fax:662-243-1095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015582Medicaid
MS212664314BOtherBCBS OF MS PROV NUMBER
MS212664314BOtherBCBS OF MS PROV NUMBER
MS256562Medicare ID - Type UnspecifiedPROVIDER NUMBER