Provider Demographics
NPI:1447403654
Name:MARTIN LEDERLY CARE LIVING
Entity Type:Organization
Organization Name:MARTIN LEDERLY CARE LIVING
Other - Org Name:SAME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ALF ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LOUISE
Authorized Official - Middle Name:LEGER
Authorized Official - Last Name:ELISE
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:305-762-4242
Mailing Address - Street 1:901 NW 63RD ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33150-4220
Mailing Address - Country:US
Mailing Address - Phone:305-762-4242
Mailing Address - Fax:305-762-4242
Practice Address - Street 1:901 NW 63RD ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33150-4220
Practice Address - Country:US
Practice Address - Phone:305-762-4242
Practice Address - Fax:305-762-4242
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:N/A
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-31
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL10144320800000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1411714200Medicaid