Provider Demographics
NPI:1104050657
Name:HOLTZ, CHARLES EDWARD JR (IDMT)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:EDWARD
Last Name:HOLTZ
Suffix:JR
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2026 SPRUCE DR
Mailing Address - Street 2:UNIT A
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58204-1864
Mailing Address - Country:US
Mailing Address - Phone:701-747-5504
Mailing Address - Fax:701-747-5923
Practice Address - Street 1:1599 J ST
Practice Address - Street 2:
Practice Address - City:GRAND FORKS AFB
Practice Address - State:ND
Practice Address - Zip Code:58205-6306
Practice Address - Country:US
Practice Address - Phone:701-747-5504
Practice Address - Fax:701-747-5923
Is Sole Proprietor?:No
Enumeration Date:2009-05-13
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians