Provider Demographics
NPI:1629424825
Name:LEA, ALICE
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:LEA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4710 SAM PECK RD
Mailing Address - Street 2:APT 2168
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-5069
Mailing Address - Country:US
Mailing Address - Phone:501-920-5083
Mailing Address - Fax:
Practice Address - Street 1:4710 SAM PECK RD
Practice Address - Street 2:APT 2168
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72223-5069
Practice Address - Country:US
Practice Address - Phone:501-920-5083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-06
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR153230343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)