Healthcare Provider Details

I. General information

NPI: 1275666794
Provider Name (Legal Business Name): LISET LIRA BA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 10/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3875 S WESTERN AVE
LOS ANGELES CA
90062-1105
US

IV. Provider business mailing address

2038 GRIFFIN AVE
LOS ANGELES CA
90031-3004
US

V. Phone/Fax

Practice location:
  • Phone: 323-290-4357
  • Fax:
Mailing address:
  • Phone: 323-803-8867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: