Basic Information
| Provider Information | |||||||||
| NPI: | 1114978475 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLLSTROM | ||||||||
| FirstName: | CLAIRE | ||||||||
| MiddleName: | ASHLEY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1555 DOCTORS DR | ||||||||
| Address2: | STE 106 | ||||||||
| City: | LAGRANGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302404139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068459370 | ||||||||
| FaxNumber: | 7068459371 | ||||||||
| Practice Location | |||||||||
| Address1: | 1555 DOCTORS DR | ||||||||
| Address2: | STE 106 | ||||||||
| City: | LAGRANGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302404139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068459370 | ||||||||
| FaxNumber: | 7068459371 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 06/09/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213EP1101X | POD000915 | GA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Primary Podiatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 918747252A | 05 | GA | MEDICAID |