1134897812 NPI number — LISAS ADVANCED PRACTICE PRIMARY CARE STAFFING CORP

Table of content: (NPI 1134897812)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134897812 NPI number — LISAS ADVANCED PRACTICE PRIMARY CARE STAFFING CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LISAS ADVANCED PRACTICE PRIMARY CARE STAFFING CORP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134897812
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
756 PIPESTONE ST STE 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BENTON HARBOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49022-4845
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
747-100-6425
Provider Business Mailing Address Fax Number:
833-906-2589

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
756 PIPESTONE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BENTON HARBOR
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49022-4845
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-926-8535
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/30/2021

Additional Information

Authorized Official

Authorized Official Last Name:
WOLSKE
Authorized Official First Name:
LISA
Authorized Official Middle Name:
JANELLE
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
269-252-1394

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com