Healthcare Provider Details

I. General information

NPI: 1912185240
Provider Name (Legal Business Name): MR. LEE OTIS MARYLAND SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2008
Last Update Date: 02/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 W GREEN ST
HAMMOND LA
70403-4807
US

IV. Provider business mailing address

119 W GREEN ST
HAMMOND LA
70403-4807
US

V. Phone/Fax

Practice location:
  • Phone: 985-351-8865
  • Fax: 775-254-9828
Mailing address:
  • Phone: 985-351-8865
  • Fax: 775-254-9828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License NumberHI.0552691
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: