Healthcare Provider Details

I. General information

NPI: 1447403654
Provider Name (Legal Business Name): MARTIN LEDERLY CARE LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2008
Last Update Date: 10/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 NW 63RD ST
MIAMI FL
33150-4220
US

IV. Provider business mailing address

901 NW 63RD ST
MIAMI FL
33150-4220
US

V. Phone/Fax

Practice location:
  • Phone: 305-762-4242
  • Fax: 305-762-4242
Mailing address:
  • Phone: 305-762-4242
  • Fax: 305-762-4242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberAL10144
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberAL10144
License Number StateFL

VIII. Authorized Official

Name: MS. LOUISE LEGER ELISE
Title or Position: ALF ADMINISTRATOR
Credential: LPN
Phone: 305-762-4242