Provider Demographics
NPI:1144979550
Name:LEILA COMMUNITY CARE
Entity type:Organization
Organization Name:LEILA COMMUNITY CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:FARDUWSA
Authorized Official - Middle Name:
Authorized Official - Last Name:HASSAN
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:404-943-0150
Mailing Address - Street 1:2940 HEBRON PARK DR STE 101
Mailing Address - Street 2:
Mailing Address - City:HEBRON
Mailing Address - State:KY
Mailing Address - Zip Code:41048-9535
Mailing Address - Country:US
Mailing Address - Phone:404-934-0150
Mailing Address - Fax:859-534-0914
Practice Address - Street 1:2940 HEBRON PARK DR STE 101
Practice Address - Street 2:
Practice Address - City:HEBRON
Practice Address - State:KY
Practice Address - Zip Code:41048-9535
Practice Address - Country:US
Practice Address - Phone:859-534-0914
Practice Address - Fax:859-534-0914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-22
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYH12-235-682Medicaid