MEDICARE: LOTTIE-ESTELLE GROUP HOME, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	315P00000X	Intellectual Disabilities Intermediate Care Facility	808	VA

General Provider Information

NPI Number	:	1053748954
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOTTIE-ESTELLE GROUP HOME, INC

Provider Business Mailing Address
First Line	:	4883 HWY 47
Second Line	:
City	:	CHASE CITY
State	:	VA
Zip	:	23924-3606
Country	:	US
Telephone Number	:	434-372-0407
Fax Number	:	434-372-0394

Provider Business Practice Location Address
First Line	:	4897 HWY 47
Second Line	:
City	:	CHASE CITY
State	:	VA
Zip	:	23924-3606
Country	:	US
Telephone Number	:	434-372-0407
Fax Number	:	434-372-0394

Authorized Official
Title or Position	:	QMRP
Name	:	MRS. TIFFANY TILLERSON TERRY
Credential	:
Telephone Number	:	434-372-0407

Provider Enumeration Date	:	10/09/2013
Last Update Date	:	10/09/2013

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