MEDICARE: MRS. MARRY IDELL TALLEY ASSOCIATES DEGREE

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1093205833
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARRY IDELL TALLEY ASSOCIATES DEGREE

Provider Business Mailing Address
First Line	:	1818 W 3RD ST
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45417-2537
Country	:	US
Telephone Number	:	937-263-8176
Fax Number	:	937-263-8175

Provider Business Practice Location Address
First Line	:	1818 W 3RD ST
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45417-2537
Country	:	US
Telephone Number	:	937-263-8176
Fax Number	:	937-263-8175

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

Provider Enumeration Date	:	05/17/2018
Last Update Date	:	05/17/2018

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