=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780024992
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LISA'S HOUSE OF LOVE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2013
-----------------------------------------------------
Last Update Date | 07/02/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2685 MORRIS ST NW UNIT 2
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30318-4542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-896-8740
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2685 MORRIS ST NW UNIT 2
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30318-4542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-896-8740
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MS. LISA NICOLE WASHINGTON
-----------------------------------------------------
Credential | NURSE AID
-----------------------------------------------------
Telephone | 770-896-8740
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------