=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467159624
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LE'AIH VERNICE HAIRSTON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2023
-----------------------------------------------------
Last Update Date | 10/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 821 BERKELEY RD
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43205-2902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 380-209-8040
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2846 BANWICK RD
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43232-3805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 380-209-8040
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 376G00000X
-----------------------------------------------------
Taxonomy Name | Nursing Home Administrator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 0327381
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------