=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194158758
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | L & L RESOURCES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2013
-----------------------------------------------------
Last Update Date | 08/17/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3720 ELIZABETH LAKE RD
-----------------------------------------------------
City | WATERFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48328-3014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-884-6770
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3720 ELIZABETH LAKE RD
-----------------------------------------------------
City | WATERFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48328-3014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-884-6770
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. CHARLES PAGE III
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-884-6770
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | SA0631357
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------