Provider Demographics
NPI:1578891412
Name:HOLMES, GLEN ALLEN (NCTMB)
Entity Type:Individual
Prefix:MR
First Name:GLEN
Middle Name:ALLEN
Last Name:HOLMES
Suffix:
Gender:M
Credentials:NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 1ST AVE W
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59912-3619
Mailing Address - Country:US
Mailing Address - Phone:406-871-1871
Mailing Address - Fax:
Practice Address - Street 1:305 1ST AVE W
Practice Address - Street 2:
Practice Address - City:COLUMBIA FALLS
Practice Address - State:MT
Practice Address - Zip Code:59912-3619
Practice Address - Country:US
Practice Address - Phone:406-871-1871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-04
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14032225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist