MEDICARE: CAROLYN MITJA

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	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1134546419
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROLYN MITJA

Provider Business Mailing Address
First Line	:	2915 ROSE AVE
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31904
Country	:	US
Telephone Number	:	706-324-1237
Fax Number	:

Provider Business Practice Location Address
First Line	:	2915 ROSE AVE
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31904
Country	:	US
Telephone Number	:	706-324-1237
Fax Number	:

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

Provider Enumeration Date	:	03/25/2014
Last Update Date	:	07/23/2014

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