Provider Demographics
NPI:1750702783
Name:LESLY'LEISURE LIVING II
Entity type:Organization
Organization Name:LESLY'LEISURE LIVING II
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:R
Authorized Official - Last Name:THELOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-661-1285
Mailing Address - Street 1:6461 NW 90TH AVE
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-3621
Mailing Address - Country:US
Mailing Address - Phone:954-724-5470
Mailing Address - Fax:954-721-9171
Practice Address - Street 1:6461 NW 90TH AVE
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-3621
Practice Address - Country:US
Practice Address - Phone:954-724-5470
Practice Address - Fax:954-721-9171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-17
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11220310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002679100Medicaid