MEDICARE: LERLENA JEANNETTE THOMAS

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	251C00000X	Developmentally Disabled Services Day Training Agency

General Provider Information

NPI Number	:	1821658147
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LERLENA JEANNETTE THOMAS

Provider Business Mailing Address
First Line	:	11430 BRANT HOLLOW CT
Second Line	:
City	:	CHESTERFIELD
State	:	VA
Zip	:	23838-8961
Country	:	US
Telephone Number	:	804-617-3159
Fax Number	:	804-318-1352

Provider Business Practice Location Address
First Line	:	4613 CHESTER SQUARE RD
Second Line	:
City	:	CHESTER
State	:	VA
Zip	:	23831-1726
Country	:	US
Telephone Number	:	804-617-3159
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/18/2019
Last Update Date	:	06/18/2019

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