MEDICARE: JT ALLEYNE ENTERPRISES, LLC

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	261QH0100X	Health Service Clinic/Center

General Provider Information

NPI Number	:	1326570813
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JT ALLEYNE ENTERPRISES, LLC

Provider Business Mailing Address
First Line	:	3575 BRIDGE RD
Second Line	:	SUITE 8 #253
City	:	SUFFOLK
State	:	VA
Zip	:	23435-1800
Country	:	US
Telephone Number	:	757-366-5423
Fax Number	:

Provider Business Practice Location Address
First Line	:	5660 INDIAN RIVER RD
Second Line	:	SUITE 101
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-5240
Country	:	US
Telephone Number	:	757-366-5423
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TYNESHIA ALLEYNE
Credential	:	LPN
Telephone Number	:	757-453-5835

Provider Enumeration Date	:	04/03/2017
Last Update Date	:	02/08/2018

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