Healthcare Provider Details

I. General information

NPI: 1306940606
Provider Name (Legal Business Name): LISENBY LLLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 06/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 WEST ELEVENTH STREET
PANAMA CITY FL
32401-1896
US

IV. Provider business mailing address

1890 STATE ROAD 436 SUITE 300
WINTER PARK FL
32792-2285
US

V. Phone/Fax

Practice location:
  • Phone: 850-785-6121
  • Fax: 850-747-3696
Mailing address:
  • Phone: 407-645-3211
  • Fax: 407-628-2853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF1296096
License Number StateFL

VIII. Authorized Official

Name: MR. KENNETH H. SCHULTZ
Title or Position: PRESIDENT
Credential:
Phone: 407-645-3211