=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821776451
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEVI HANKWALE MAKALA DVM, MBA, MAT, PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2023
-----------------------------------------------------
Last Update Date | 07/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4933 HEREFORD FARM RD
-----------------------------------------------------
City | EVANS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30809-6005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-832-3379
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | LILY OF THE VALLEY ADULT CARE SOLUTIONS (LOVACS) LLC 4933 HEREFORD FARM RD
-----------------------------------------------------
City | EVANS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30809-6005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-832-3379
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | PCH010216
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------