MEDICARE: LEUMAS LIGHTED LIFE, LLC

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	251S00000X	Community/Behavioral Health Agency	2019-01-001	VA

General Provider Information

NPI Number	:	1265820880
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEUMAS LIGHTED LIFE, LLC

Provider Business Mailing Address
First Line	:	32 W CLAY ST
Second Line	:
City	:	SALEM
State	:	VA
Zip	:	24153-3754
Country	:	US
Telephone Number	:	540-354-5565
Fax Number	:	540-387-0058

Provider Business Practice Location Address
First Line	:	32 W CLAY ST
Second Line	:
City	:	SALEM
State	:	VA
Zip	:	24153-3754
Country	:	US
Telephone Number	:	540-354-5565
Fax Number	:	540-387-0058

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MRS. SHIRLEY HAIRSTON EVERETT
Credential	:
Telephone Number	:	540-354-5565

Provider Enumeration Date	:	01/05/2015
Last Update Date	:	01/05/2015

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