MEDICARE: LISAS ADVANCED PRACTICE PRIMARY CARE STAFFING CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1134897812
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LISAS ADVANCED PRACTICE PRIMARY CARE STAFFING CORP

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

Provider Business Practice Location Address
First Line	:	756 PIPESTONE ST
Second Line	:
City	:	BENTON HARBOR
State	:	MI
Zip	:	49022-4845
Country	:	US
Telephone Number	:	269-926-8535
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	LISA JANELLE WOLSKE
Credential	:	NP
Telephone Number	:	269-252-1394

Provider Enumeration Date	:	08/30/2021
Last Update Date	:	12/22/2021

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Directions to “LISAS ADVANCED PRACTICE PRIMARY CARE STAFFING CORP ” Practice Location

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