Healthcare Provider Details

I. General information

NPI: 1326227059
Provider Name (Legal Business Name): WANDA HOLMES CST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2007
Last Update Date: 10/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 W 15TH ST
PLANO TX
75075-7738
US

IV. Provider business mailing address

PO BOX 118932
CARROLLTON TX
75011-8932
US

V. Phone/Fax

Practice location:
  • Phone: 817-294-7444
  • Fax:
Mailing address:
  • Phone: 817-294-7444
  • Fax: 817-294-7172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: