MEDICARE: JULIA SAMPLE

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275290959
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULIA SAMPLE

Provider Business Mailing Address
First Line	:	17412 LAKE VISTA DR
Second Line	:
City	:	GREENWELL SPRINGS
State	:	LA
Zip	:	70739-4757
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	17412 LAKE VISTA DR
Second Line	:
City	:	GREENWELL SPRINGS
State	:	LA
Zip	:	70739-4757
Country	:	US
Telephone Number	:	225-907-8843
Fax Number	:

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

Provider Enumeration Date	:	11/17/2021
Last Update Date	:	11/17/2021

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Directions to “ JULIA SAMPLE ” Practice Location

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