MEDICARE: LEA'S ASSISTED LIVING #1, 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	310400000X	Assisted Living Facility	HAL-093-009	NC

General Provider Information

NPI Number	:	1275763039
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEA'S ASSISTED LIVING #1, INC.

Provider Business Mailing Address
First Line	:	962 MANSON AXTELL RD
Second Line	:
City	:	NORLINA
State	:	NC
Zip	:	27563-9451
Country	:	US
Telephone Number	:	252-456-2090
Fax Number	:	252-456-5118

Provider Business Practice Location Address
First Line	:	962 MANSON AXTELL RD
Second Line	:
City	:	NORLINA
State	:	NC
Zip	:	27563-9451
Country	:	US
Telephone Number	:	252-456-2090
Fax Number	:	252-456-5118

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. LINDA P. LEA
Credential	:
Telephone Number	:	252-456-2090

Provider Enumeration Date	:	07/15/2009
Last Update Date	:	07/15/2009

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