Provider Demographics
NPI:1568159994
Name:MATHIS, LESLIE J
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:J
Last Name:MATHIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3911 WAYCROSS RD
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:NC
Mailing Address - Zip Code:28453-8091
Mailing Address - Country:US
Mailing Address - Phone:562-257-4856
Mailing Address - Fax:
Practice Address - Street 1:3911 WAYCROSS RD
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:NC
Practice Address - Zip Code:28453-8091
Practice Address - Country:US
Practice Address - Phone:562-257-4856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home