=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881476653
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMIE MAE HOLCHIN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2023
-----------------------------------------------------
Last Update Date | 10/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1970 ROANOKE BLVD
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24153-6404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-982-2463
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3338 CIRCLE BROOK DR APT K
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24018-7230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-514-3339
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291900000X
-----------------------------------------------------
Taxonomy Name | Military Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------