MEDICARE: LISA DENISE SANFORD

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	171000000X	Military Health Care Provider

General Provider Information

NPI Number	:	1326521725
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA DENISE SANFORD

Provider Business Mailing Address
First Line	:	2750 W WIGWAM AVE APT 2169
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-6656
Country	:	US
Telephone Number	:	323-706-2161
Fax Number	:

Provider Business Practice Location Address
First Line	:	2750 W WIGWAM AVE APT 2169
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-6656
Country	:	US
Telephone Number	:	323-706-2161
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/11/2018
Last Update Date	:	09/11/2018

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