Provider Demographics
NPI:1629545561
Name:TELLY JAYA TRANSPORTATION, LLC
Entity Type:Organization
Organization Name:TELLY JAYA TRANSPORTATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SANJAYA
Authorized Official - Middle Name:SATRIYA
Authorized Official - Last Name:UTAMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:661-886-0287
Mailing Address - Street 1:190 SIERRA CT.
Mailing Address - Street 2:UNIT B # A-115
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93550-7607
Mailing Address - Country:US
Mailing Address - Phone:661-886-0287
Mailing Address - Fax:661-213-9733
Practice Address - Street 1:190 SIERRA CT.
Practice Address - Street 2:UNIT B # A-115
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-7607
Practice Address - Country:US
Practice Address - Phone:661-886-0285
Practice Address - Fax:661-213-9733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-29
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)