Provider Demographics
NPI:1366064081
Name:HOLM, RANDALL ODVAR (LMT 5009)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:ODVAR
Last Name:HOLM
Suffix:
Gender:M
Credentials:LMT 5009
Other - Prefix:
Other - First Name:RANDALL
Other - Middle Name:ODVAR
Other - Last Name:HOLM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT 5009
Mailing Address - Street 1:106 BLAKE AVE
Mailing Address - Street 2:
Mailing Address - City:MUSCLE SHOALS
Mailing Address - State:AL
Mailing Address - Zip Code:35661-1206
Mailing Address - Country:US
Mailing Address - Phone:256-366-2261
Mailing Address - Fax:
Practice Address - Street 1:1104 BRADSHAW DR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-1438
Practice Address - Country:US
Practice Address - Phone:256-229-3665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-15
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist