Provider Demographics
NPI:1386095412
Name:HOLMES, MICHAEL (LAT, ATC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:HOLMES
Suffix:
Gender:
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 1:1542 WEBSTER ST
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-3533
Mailing Address - Country:US
Mailing Address - Phone:517-899-1879
Mailing Address - Fax:
Practice Address - Street 1:3946 ICE WAY
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-1018
Practice Address - Country:US
Practice Address - Phone:260-266-4005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-30
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT66802255A2300X
COAT.00018132255A2300X
IN36003136A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer