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General NPI Number Information
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NPI Number | 1447403654
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Entity Type | Organization
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Legal Business Name | MARTIN LEDERLY CARE LIVING
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Dates
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Enumeration Date | 10/31/2008
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Last Update Date | 10/31/2008
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Provider Practice Location Address
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Address Line | 901 NW 63RD ST
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City | MIAMI
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State | FL
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Zip | 33150-4220
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Country | US
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Telephone | 305-762-4242
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Fax | 305-762-4242
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Provider Business Mailing Address
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Address Line | 901 NW 63RD ST
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City | MIAMI
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State | FL
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Zip | 33150-4220
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Country | US
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Telephone | 305-762-4242
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Fax | 305-762-4242
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Authorized Official
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Title or Position | ALF ADMINISTRATOR
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Name | MS. LOUISE LEGER ELISE
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Credential | LPN
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Telephone | 305-762-4242
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number | AL10144
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number | AL10144
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License Number State | FL
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