Provider Demographics
NPI:1790096352
Name:LEISON HOMES
Entity Type:Organization
Organization Name:LEISON HOMES
Other - Org Name:LEISON HOUSE AFC
Other - Org Type:Other Name
Authorized Official - Title/Position:LICENSEE
Authorized Official - Prefix:
Authorized Official - First Name:DENA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-686-1160
Mailing Address - Street 1:124 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:ALLEGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49010-1426
Mailing Address - Country:US
Mailing Address - Phone:269-686-1160
Mailing Address - Fax:269-355-6206
Practice Address - Street 1:124 JAMES ST
Practice Address - Street 2:
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010-1426
Practice Address - Country:US
Practice Address - Phone:269-686-1160
Practice Address - Fax:269-355-6206
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEISON HOMES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-06-29
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF030238133320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3868837OtherMICHIGAN DEPARTMENT OF COMMUNITY HEALTH