Basic Information
| Provider Information | |||||||||
| NPI: | 1659475960 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLMES | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 CARDINAL DR | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329513732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216522643 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7341 OFFICE PARK PL STE 102 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329408280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216906612 | ||||||||
| FaxNumber: | 3216902630 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2006 | ||||||||
| LastUpdateDate: | 05/02/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501009015 | MI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT33131 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 33131 | 01 | FL | FLORIDA STATE LICENSE | OTHER | VAD000 | 05 | MI | MEDICAID |