MEDICARE: STACIE G HOLMES PROSTHESIS TRAINER

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	335E00000X	Prosthetic/Orthotic Supplier

General Provider Information

NPI Number	:	1578117867
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACIE G HOLMES PROSTHESIS TRAINER

Provider Business Mailing Address
First Line	:	818 RENAISSANCE POINTE
Second Line	:
City	:	ALTAMONTE SPRINGS
State	:	FL
Zip	:	32714-3537
Country	:	US
Telephone Number	:	407-844-3205
Fax Number	:

Provider Business Practice Location Address
First Line	:	801 W STATE ROAD 436 STE 2013
Second Line	:
City	:	ALTAMONTE SPRINGS
State	:	FL
Zip	:	32714-3053
Country	:	US
Telephone Number	:	407-844-3205
Fax Number	:	407-917-9688

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

Provider Enumeration Date	:	07/25/2019
Last Update Date	:	07/01/2020

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