Provider Demographics
NPI:1700232139
Name:GRAY-LESLIE ROWENA
Entity Type:Organization
Organization Name:GRAY-LESLIE ROWENA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROWENA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GRAY-LESLIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-801-8492
Mailing Address - Street 1:27409 HAMMOCK VIEW CT
Mailing Address - Street 2:
Mailing Address - City:YALAHA
Mailing Address - State:FL
Mailing Address - Zip Code:34797
Mailing Address - Country:US
Mailing Address - Phone:443-801-8492
Mailing Address - Fax:
Practice Address - Street 1:27409 HAMMOCK VIEW CT
Practice Address - Street 2:
Practice Address - City:YALAHA
Practice Address - State:FL
Practice Address - Zip Code:34797-3093
Practice Address - Country:US
Practice Address - Phone:443-801-8492
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-04
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906852311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home