1093942385 NPI number — LEE STREET DEVELOPERS LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093942385 NPI number — LEE STREET DEVELOPERS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEE STREET DEVELOPERS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ROSE OF SHARON'S SENIOR VILLA
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093942385
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/03/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5410 LEE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHATTANOOGA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37410-2219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-822-7673
Provider Business Mailing Address Fax Number:
423-821-2468

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5410 LEE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHATTANOOGA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37410-2219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-822-7673
Provider Business Practice Location Address Fax Number:
423-821-2468
Provider Enumeration Date:
06/15/2009

Additional Information

Authorized Official

Authorized Official Last Name:
HUDGINS
Authorized Official First Name:
CHERI
Authorized Official Middle Name:
TANEKA
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
423-822-7673

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  ACL0000000292 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 385H00000X , with the licence number: ACL000000292 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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