MEDICARE: SOUTHERN ASSISTED LIVING, 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	310400000X	Assisted Living Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659437218
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN ASSISTED LIVING, LLC.

Provider Business Mailing Address
First Line	:	6737 W WASHINGTON ST
Second Line	:	SUITE 2300
City	:	MILWAUKEE
State	:	WI
Zip	:	53214-5647
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1316 PATTERSON AVENUE
Second Line	:
City	:	MONROE
State	:	NC
Zip	:	28112
Country	:	US
Telephone Number	:	704-282-0530
Fax Number	:	704-296-9058

Authorized Official
Title or Position	:	SENIOR VICE PRESIDENT
Name	:	JOANNE K LESKOWICZ
Credential	:
Telephone Number	:	414-918-5000

Provider Enumeration Date	:	12/28/2006
Last Update Date	:	04/08/2021

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