MEDICARE: JLW PLACE 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	332B00000X	Durable Medical Equipment & Medical Supplies	2-044907	AL
2	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	2-044907	AL

General Provider Information

NPI Number	:	1265665814
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JLW PLACE INC.

Provider Business Mailing Address
First Line	:	PO BOX 497
Second Line	:
City	:	SARALAND
State	:	AL
Zip	:	36571-0497
Country	:	US
Telephone Number	:	251-367-2139
Fax Number	:	251-442-0706

Provider Business Practice Location Address
First Line	:	472 LOTT RD
Second Line	:
City	:	EIGHT MILE
State	:	AL
Zip	:	36613-3533
Country	:	US
Telephone Number	:	251-367-2139
Fax Number	:	251-442-0706

Authorized Official
Title or Position	:	OWNER
Name	:	MR. CHRISTOPHER WILLIAMS SR.
Credential	:	LPN
Telephone Number	:	251-367-2139

Provider Enumeration Date	:	08/31/2009
Last Update Date	:	08/31/2009

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