Provider Demographics
NPI:1760622062
Name:THOMAS R. HOLMES, DBA DEMENTIA
Entity Type:Organization
Organization Name:THOMAS R. HOLMES, DBA DEMENTIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-561-9676
Mailing Address - Street 1:2358 MIRABEAU DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-5867
Mailing Address - Country:US
Mailing Address - Phone:903-561-9676
Mailing Address - Fax:
Practice Address - Street 1:2358 MIRABEAU DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-5867
Practice Address - Country:US
Practice Address - Phone:903-561-9676
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-25
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109348225XG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1134346380OtherINDIVIDUAL PROVIDER NPI
TX8F20511Medicare Oscar/Certification
TX0A3329Medicare Oscar/Certification