=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053128637
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAYLEN LEANDRE HOLMES
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2024
-----------------------------------------------------
Last Update Date | 12/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 579 SIMONTON OAK LN
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30045-3525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-476-1877
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 579 SIMONTON OAK LN
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30045-3525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-476-1877
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number | 060490575
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------