MEDICARE: CARLOS HOLMES

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	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1346427085
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLOS HOLMES

Provider Business Mailing Address
First Line	:	1112 WEST 112TH ST.
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90044
Country	:	US
Telephone Number	:	323-686-4578
Fax Number	:

Provider Business Practice Location Address
First Line	:	1704 W MANCHESTER AVE STE 105
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90047-3056
Country	:	US
Telephone Number	:	323-759-6224
Fax Number	:

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

Provider Enumeration Date	:	01/24/2008
Last Update Date	:	01/24/2008

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