Healthcare Provider Details

I. General information

NPI: 1902295512
Provider Name (Legal Business Name): LYSAL PROF. MKTG. & HOME HEALTHCARE MNGMT. GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2015
Last Update Date: 01/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7225 SHARBETH DR S
JACKSONVILLE FL
32210-4753
US

IV. Provider business mailing address

7225 SHARBETH DR S
JACKSONVILLE FL
32210-4753
US

V. Phone/Fax

Practice location:
  • Phone: 855-334-3339
  • Fax: 904-573-2610
Mailing address:
  • Phone: 855-334-3339
  • Fax: 904-573-2610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH8370
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License NumberARNP9300116
License Number StateFL

VIII. Authorized Official

Name: CHANDA LYNN MOORE
Title or Position: CEO
Credential: BS
Phone: 904-759-5089