Provider Demographics
NPI:1851181663
Name:GLY COMMUNITY SUPPORT SERVICE LLC
Entity type:Organization
Organization Name:GLY COMMUNITY SUPPORT SERVICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAKESHA
Authorized Official - Middle Name:TYJUAN
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-758-6333
Mailing Address - Street 1:1646 PORTER LAKES DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-8321
Mailing Address - Country:US
Mailing Address - Phone:904-758-6333
Mailing Address - Fax:
Practice Address - Street 1:1646 PORTER LAKES DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-8321
Practice Address - Country:US
Practice Address - Phone:904-758-6333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-07
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No253Z00000XAgenciesIn Home Supportive Care
No344600000XTransportation ServicesTaxi
No347B00000XTransportation ServicesBus
No347C00000XTransportation ServicesPrivate Vehicle