MEDICARE: MR. JEROME TALLEY CNA

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	374U00000X	Home Health Aide	126167LGB	GA

General Provider Information

NPI Number	:	1275746257
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEROME TALLEY CNA

Provider Business Mailing Address
First Line	:	1135 MONTREAT AVE SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30310-3322
Country	:	US
Telephone Number	:	404-438-7530
Fax Number	:

Provider Business Practice Location Address
First Line	:	1135 MONTREAT AVE SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30310-3322
Country	:	US
Telephone Number	:	404-438-7530
Fax Number	:

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

Provider Enumeration Date	:	05/07/2007
Last Update Date	:	07/08/2007

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