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General NPI Number Information
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NPI Number | 1326512971
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Entity Type | Organization
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Legal Business Name | LILLY OF THE VALLEY LLC
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Dates
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Enumeration Date | 01/16/2019
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Last Update Date | 01/16/2019
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Provider Practice Location Address
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Address Line | 5651 WOODCREST AVE
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City | PHILADELPHIA
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State | PA
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Zip | 19131-1303
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Country | US
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Telephone | 267-902-2343
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Fax |
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Provider Business Mailing Address
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Address Line | 4061 FILBERT ST
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City | PHILADELPHIA
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State | PA
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Zip | 19104-2256
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Country | US
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Telephone | 215-662-3094
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | SHANICE JENKINS
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Credential |
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Telephone | 267-902-2343
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 373H00000X
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Taxonomy Name | Day Training/Habilitation Specialist
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License Number |
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License Number State |
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