Healthcare Provider Details

I. General information

NPI: 1932558053
Provider Name (Legal Business Name): LEES PERSONAL ASSISTED LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2016
Last Update Date: 06/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 S 6TH AVE 105 SOUTH 6 AVENUE
LANETT AL
36863-2415
US

IV. Provider business mailing address

105 S 6TH AVE 105 SOUTH 6 AVENUE
LANETT AL
36863-2415
US

V. Phone/Fax

Practice location:
  • Phone: 706-773-5792
  • Fax: 334-644-4441
Mailing address:
  • Phone: 706-773-5792
  • Fax: 334-644-4441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number259316257
License Number StateAL

VIII. Authorized Official

Name: MS. JACOBIE JEAN DARDY
Title or Position: OWNER/ADM.
Credential: N/A
Phone: 706-773-5792