Provider Demographics
NPI:1639698228
Name:HOLMES, ACACIA (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:ACACIA
Middle Name:
Last Name:HOLMES
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 S PARK RIDGE RD APT 11304
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-8315
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1025 E 7TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47405-7109
Practice Address - Country:US
Practice Address - Phone:414-418-5226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-14
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer