Provider Demographics
NPI:1831440221
Name:JANINE TALTY LLC
Entity type:Organization
Organization Name:JANINE TALTY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JANINE
Authorized Official - Middle Name:
Authorized Official - Last Name:TALTY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:540-685-2670
Mailing Address - Street 1:2702 BRAMBLETON AVE SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-4308
Mailing Address - Country:US
Mailing Address - Phone:540-685-2670
Mailing Address - Fax:540-685-2671
Practice Address - Street 1:2702 BRAMBLETON AVE SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24015-4308
Practice Address - Country:US
Practice Address - Phone:831-426-7585
Practice Address - Fax:831-426-6224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-25
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102202736204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0102202736OtherLICENSE