Basic Information
Provider Information | |||||||||
NPI: | 1659340537 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SP LEE LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LEE HEALTH & REHAB CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5372 FALLOWATER LN | ||||||||
Address2: | SUITE 200 | ||||||||
City: | ROANOKE | ||||||||
State: | VA | ||||||||
PostalCode: | 240180907 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5407258910 | ||||||||
FaxNumber: | 5407258914 | ||||||||
Practice Location | |||||||||
Address1: | 208 HEALTH CARE DR | ||||||||
Address2: |   | ||||||||
City: | PENNINGTON GAP | ||||||||
State: | VA | ||||||||
PostalCode: | 242772854 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2765464566 | ||||||||
FaxNumber: | 2765466818 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/14/2006 | ||||||||
LastUpdateDate: | 01/13/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ALESANTRINO | ||||||||
AuthorizedOfficialFirstName: | JOSEPH | ||||||||
AuthorizedOfficialMiddleName: | ANTHONY | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 5407258910 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/13/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH2746 | VA | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 004953525 | 05 | VA |   | MEDICAID | 144883 | 01 |   | MEDIGAP # MEDICARE B | OTHER | 198187 | 01 | VA | ANTHEM/BLUE CROSS | OTHER |