Healthcare Provider Details

I. General information

NPI: 1831440221
Provider Name (Legal Business Name): JANINE TALTY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2012
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2702 BRAMBLETON AVE SW
ROANOKE VA
24015-4308
US

IV. Provider business mailing address

2702 BRAMBLETON AVE SW
ROANOKE VA
24015-4308
US

V. Phone/Fax

Practice location:
  • Phone: 831-426-7585
  • Fax: 831-426-6224
Mailing address:
  • Phone: 540-685-2670
  • Fax: 540-685-2671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number0102202736
License Number StateVA

VIII. Authorized Official

Name: JANINE TALTY
Title or Position: PHYSICIAN
Credential: D.O.
Phone: 540-685-2670