Provider Demographics
NPI:1255391421
Name:SHAWN LEACH-MANLEY
Entity type:Organization
Organization Name:SHAWN LEACH-MANLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEACH-MANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-997-3857
Mailing Address - Street 1:2510 HALLIE MILL RD
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30349-4927
Mailing Address - Country:US
Mailing Address - Phone:770-997-3857
Mailing Address - Fax:770-997-9489
Practice Address - Street 1:2510 HALLIE MILL RD
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349-4927
Practice Address - Country:US
Practice Address - Phone:770-997-3857
Practice Address - Fax:770-997-9489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00942697AMedicaid
GA1317470001Medicare PIN
GA1317470001Medicare NSC