Provider Demographics
NPI:1821324856
Name:HOLMES, AVERY JEROME (IDC)
Entity Type:Individual
Prefix:
First Name:AVERY
Middle Name:JEROME
Last Name:HOLMES
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 SILKY CT
Mailing Address - Street 2:
Mailing Address - City:RICHLANDS
Mailing Address - State:NC
Mailing Address - Zip Code:28574-7418
Mailing Address - Country:US
Mailing Address - Phone:910-787-6358
Mailing Address - Fax:
Practice Address - Street 1:BUILDING HP217 F ST
Practice Address - Street 2:BATTALION AID STATION 1ST BATTALION 2ND MARINES
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542-0094
Practice Address - Country:US
Practice Address - Phone:910-451-3607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-27
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman