Provider Demographics
NPI:1023761483
Name:HOLLIS, CHARLES DANE (LAC)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:DANE
Last Name:HOLLIS
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:S30W30370 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53189-9007
Mailing Address - Country:US
Mailing Address - Phone:229-733-7980
Mailing Address - Fax:
Practice Address - Street 1:4813 W NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53214-3523
Practice Address - Country:US
Practice Address - Phone:414-502-8235
Practice Address - Fax:414-921-9772
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-26
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1041-55171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist