Healthcare Provider Details

I. General information

NPI: 1093288136
Provider Name (Legal Business Name): LISA G ROZENTAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2019
Last Update Date: 01/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 LOS ARBOR DR
DELAND FL
32724-1263
US

IV. Provider business mailing address

120 LOS ARBOR DR
DELAND FL
32724-1263
US

V. Phone/Fax

Practice location:
  • Phone: 386-717-6150
  • Fax: 386-873-7387
Mailing address:
  • Phone: 386-717-6150
  • Fax: 386-873-7387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number015394200
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: