Provider Demographics
NPI:1225246572
Name:LEISURE HOME LIFE, INC.
Entity Type:Organization
Organization Name:LEISURE HOME LIFE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TEMPSIE
Authorized Official - Middle Name:DAVIS
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:252-641-4107
Mailing Address - Street 1:PO BOX 2087
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27802-2087
Mailing Address - Country:US
Mailing Address - Phone:252-641-4107
Mailing Address - Fax:252-973-8599
Practice Address - Street 1:800 E SAINT JOHN ST
Practice Address - Street 2:
Practice Address - City:TARBORO
Practice Address - State:NC
Practice Address - Zip Code:27886-4544
Practice Address - Country:US
Practice Address - Phone:252-641-4107
Practice Address - Fax:252-973-8599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC780233Medicaid