Basic Information
| Provider Information | |||||||||
| NPI: | 1194718536 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLLER | ||||||||
| FirstName: | ALTAGRACIA | ||||||||
| MiddleName: | LOPEZ | ||||||||
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| Credential: | OD | ||||||||
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| OtherLastName: | LOPEZ | ||||||||
| OtherFirstName: | ALTAGRACIA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7100 SIX FORKS RD | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276156156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198470187 | ||||||||
| FaxNumber: | 9196762231 | ||||||||
| Practice Location | |||||||||
| Address1: | 2042 KILDAIRE FARM RD | ||||||||
| Address2: | |||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275116614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198519995 | ||||||||
| FaxNumber: | 9198594172 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2005 | ||||||||
| LastUpdateDate: | 05/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1730 | NC | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 0923A | 01 | NC | BLUECROSS | OTHER | 890923A | 05 | NC | MEDICAID | 410048142 | 01 | NC | RAILROAD MEDICARE | OTHER |