Provider Demographics
NPI:1992304281
Name:HOLMES PERSONAL CARE AGENCY LLC
Entity type:Organization
Organization Name:HOLMES PERSONAL CARE AGENCY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:J
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:141-207-1852
Mailing Address - Street 1:10111 W CAPITOL DR STE 8
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-1335
Mailing Address - Country:US
Mailing Address - Phone:414-207-1852
Mailing Address - Fax:414-444-7896
Practice Address - Street 1:10111 W CAPITOL DR STE 8
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-1335
Practice Address - Country:US
Practice Address - Phone:414-207-1852
Practice Address - Fax:414-444-7896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100102242Medicaid