Provider Demographics
NPI:1912185240
Name:MARYLAND, LEE OTIS SR
Entity Type:Individual
Prefix:MR
First Name:LEE
Middle Name:OTIS
Last Name:MARYLAND
Suffix:SR
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 1:119 W GREEN ST
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403-4807
Mailing Address - Country:US
Mailing Address - Phone:985-351-8865
Mailing Address - Fax:775-254-9828
Practice Address - Street 1:119 W GREEN ST
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-4807
Practice Address - Country:US
Practice Address - Phone:985-351-8865
Practice Address - Fax:775-254-9828
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-08
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAHI.0552691171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications