MEDICARE: MR. CARLOS LAMONT BAILEY

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	172A00000X	Driver	2330905299	IN

General Provider Information

NPI Number	:	1306356795
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CARLOS LAMONT BAILEY

Provider Business Mailing Address
First Line	:	3239 TANSEL RD UNIT 34035
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46234-4601
Country	:	US
Telephone Number	:	317-362-6234
Fax Number	:	317-377-4539

Provider Business Practice Location Address
First Line	:	3239 TANSEL RD UNIT 34035
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46234-4601
Country	:	US
Telephone Number	:	317-362-6234
Fax Number	:	317-377-4539

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

Provider Enumeration Date	:	10/11/2017
Last Update Date	:	10/11/2017

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Directions to “ MR. CARLOS LAMONT BAILEY ” Practice Location

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