Provider Demographics
NPI:1124269089
Name:P O HOLLIDAY III FAMILY LEASING CO LLC
Entity type:Organization
Organization Name:P O HOLLIDAY III FAMILY LEASING CO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:O
Authorized Official - Last Name:HOLLIDAY
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:478-474-0394
Mailing Address - Street 1:420 CHARTER BLVD
Mailing Address - Street 2:STE 402
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-4854
Mailing Address - Country:US
Mailing Address - Phone:478-474-0394
Mailing Address - Fax:478-477-5509
Practice Address - Street 1:420 CHARTER BLVD
Practice Address - Street 2:STE 402
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-4854
Practice Address - Country:US
Practice Address - Phone:478-474-0394
Practice Address - Fax:478-477-5509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-23
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA026557332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00289528BMedicaid
GA00289528BMedicaid
GA6172380001Medicare NSC