=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700232139
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRAY-LESLIE ROWENA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2016
-----------------------------------------------------
Last Update Date | 05/04/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27409 HAMMOCK VIEW CT
-----------------------------------------------------
City | YALAHA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34797-3093
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-801-8492
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27409 HAMMOCK VIEW CT
-----------------------------------------------------
City | YALAHA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34797
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-801-8492
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ROWENA M GRAY-LESLIE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 443-801-8492
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | 6906852
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------