MEDICARE: MR. KALANTE K HOLMES CCDC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	104224	CA

General Provider Information

NPI Number	:	1154541357
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KALANTE K HOLMES CCDC

Provider Business Mailing Address
First Line	:	2872 CLARENDON AVE APT E
Second Line	:
City	:	HUNTINGTON PARK
State	:	CA
Zip	:	90255-4352
Country	:	US
Telephone Number	:	323-793-7550
Fax Number	:

Provider Business Practice Location Address
First Line	:	11901 SANTA MONICA BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-2767
Country	:	US
Telephone Number	:	310-268-2446
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/27/2007
Last Update Date	:	07/08/2007

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