Provider Demographics
NPI:1215101282
Name:LILLYES HEART
Entity type:Organization
Organization Name:LILLYES HEART
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:LEANDRA
Authorized Official - Middle Name:E
Authorized Official - Last Name:STAFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-722-3301
Mailing Address - Street 1:8387 CENTURY POINT DR N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-9286
Mailing Address - Country:US
Mailing Address - Phone:904-722-3301
Mailing Address - Fax:904-722-3302
Practice Address - Street 1:8387 CENTURY POINT DR N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-9286
Practice Address - Country:US
Practice Address - Phone:904-722-3301
Practice Address - Fax:904-722-3302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-21
Last Update Date:2008-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL689238896251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL689238896Medicaid
FL689238898Medicaid