Provider Demographics
NPI:1699370494
Name:HOLMES GRAY, STACI (PHLEBOTOMIST)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:HOLMES GRAY
Suffix:
Gender:F
Credentials:PHLEBOTOMIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 N PACIFIC COAST HWY STE 2000
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-4532
Mailing Address - Country:US
Mailing Address - Phone:987-214-7117
Mailing Address - Fax:
Practice Address - Street 1:360 N PACIFIC COAST HWY STE 2000
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-4532
Practice Address - Country:US
Practice Address - Phone:987-214-7117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-01
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00021865246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy