Healthcare Provider Details

I. General information

NPI: 1659752947
Provider Name (Legal Business Name): MRS. ELIZABETH LEZAMA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2015
Last Update Date: 04/13/2020
Certification Date: 04/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 SPRUCE ST
RIVERSIDE CA
92507-2464
US

IV. Provider business mailing address

71687 HIGHWAY 111
RANCHO MIRAGE CA
92270-4515
US

V. Phone/Fax

Practice location:
  • Phone: 951-715-5050
  • Fax:
Mailing address:
  • Phone: 442-256-6056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: