Provider Demographics
NPI:1316096431
Name:MARSHA JORDAN HOLLOWAY, LLC
Entity type:Organization
Organization Name:MARSHA JORDAN HOLLOWAY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-293-1360
Mailing Address - Street 1:1525 BAYTREE RD
Mailing Address - Street 2:SUITE I
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2786
Mailing Address - Country:US
Mailing Address - Phone:229-293-1360
Mailing Address - Fax:229-293-1356
Practice Address - Street 1:1525 BAYTREE RD
Practice Address - Street 2:SUITE I
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2786
Practice Address - Country:US
Practice Address - Phone:229-293-1360
Practice Address - Fax:229-293-1356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0106881223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty