Basic Information
| Provider Information | |||||||||
| NPI: | 1922514983 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLMES | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | EAVES | ||||||||
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| Credential: | PT, DPT | ||||||||
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| OtherLastName: | HOLMES | ||||||||
| OtherFirstName: | ANDREA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1110 SHAWNEE RD | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458053529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194978414 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1501 N BICKETT BLVD STE F | ||||||||
| Address2: | |||||||||
| City: | LOUISBURG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275492178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194978414 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2017 | ||||||||
| LastUpdateDate: | 01/14/2019 | ||||||||
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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 | 225100000X | 17647 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.