Basic Information
| Provider Information | |||||||||
| NPI: | 1750657128 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLLOWAY | ||||||||
| FirstName: | BETTY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | N57W24950 N CORPORATE CIR | ||||||||
| Address2: | PROHEALTH CARE MEDICAL ASSOCIATES INC. | ||||||||
| City: | SUSSEX | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530894383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2628203093 | ||||||||
| FaxNumber: | 2625329598 | ||||||||
| Practice Location | |||||||||
| Address1: | N57W24950 N CORPORATE CIR | ||||||||
| Address2: | PROHEALTH CARE MEDICAL ASSOCIATES INC. | ||||||||
| City: | SUSSEX | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530894383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2628203093 | ||||||||
| FaxNumber: | 2625329598 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2012 | ||||||||
| LastUpdateDate: | 03/29/2012 | ||||||||
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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 | 133N00000X | 2208 | WI | Y | Dietary & Nutritional Service Providers | Nutritionist |
No ID Information.