Healthcare Provider Details

I. General information

NPI: 1053712125
Provider Name (Legal Business Name): LYSAL ENTERPRISES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2014
Last Update Date: 09/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7215 ZAPATA DR
JACKSONVILLE FL
32210-4772
US

IV. Provider business mailing address

7215 ZAPATA DR
JACKSONVILLE FL
32210-4772
US

V. Phone/Fax

Practice location:
  • Phone: 904-759-5089
  • Fax: 904-573-2610
Mailing address:
  • Phone: 904-759-5089
  • Fax: 904-573-2610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code364SH0200X
TaxonomyHome Health Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: MRS. CHANDA L. MOORE
Title or Position: CEO
Credential:
Phone: 904-759-5089