Healthcare Provider Details

I. General information

NPI: 1871085084
Provider Name (Legal Business Name): LISA KAY HUSEBOE DC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2018
Last Update Date: 07/27/2024
Certification Date: 07/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10650 W STATE ROAD 84 STE 208
DAVIE FL
33324-4235
US

IV. Provider business mailing address

10650 W STATE ROAD 84 STE 208
DAVIE FL
33324-4235
US

V. Phone/Fax

Practice location:
  • Phone: 754-778-8685
  • Fax: 954-208-9854
Mailing address:
  • Phone: 754-778-8685
  • Fax: 954-208-9854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License NumberCH6941
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: