Provider Demographics
NPI:1790354025
Name:HOLMES, DUSTIN DRU (RD)
Entity Type:Individual
Prefix:MR
First Name:DUSTIN
Middle Name:DRU
Last Name:HOLMES
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 WARREN PL
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302-3613
Mailing Address - Country:US
Mailing Address - Phone:304-389-3336
Mailing Address - Fax:
Practice Address - Street 1:15 WARREN PL
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-3613
Practice Address - Country:US
Practice Address - Phone:304-389-3336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-21
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1107133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered