=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366855876
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GODLY AMBITION OF NEW GENERATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2014
-----------------------------------------------------
Last Update Date | 06/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3501 E WINLARK DR
-----------------------------------------------------
City | FLORENCE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29506-8637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-621-2696
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3501 E WINLARK DR
-----------------------------------------------------
City | FLORENCE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29506-8637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-621-2696
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM DIRECTOR
-----------------------------------------------------
Name | DEANN G LESANE
-----------------------------------------------------
Credential | MA, AS
-----------------------------------------------------
Telephone | 843-621-2696
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305R00000X
-----------------------------------------------------
Taxonomy Name | Preferred Provider Organization
-----------------------------------------------------
License Number | 1042065
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------