Provider Demographics
NPI:1699748509
Name:HOLMES, RONALD C (PT)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:C
Last Name:HOLMES
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6955 NDCBU
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571
Mailing Address - Country:US
Mailing Address - Phone:505-758-8761
Mailing Address - Fax:505-751-0448
Practice Address - Street 1:414 SIPAPU ST
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571
Practice Address - Country:US
Practice Address - Phone:505-758-8761
Practice Address - Fax:505-751-0448
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM262225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMN5566Medicaid
NMN5566Medicaid