Healthcare Provider Details

I. General information

NPI: 1245066380
Provider Name (Legal Business Name): LISAMEL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2024
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19950 TORRENCE AVE
LYNWOOD IL
60411-7614
US

IV. Provider business mailing address

19950 TORRENCE AVE
LYNWOOD IL
60411-7614
US

V. Phone/Fax

Practice location:
  • Phone: 708-243-1169
  • Fax:
Mailing address:
  • Phone: 708-243-1169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: LISA JETER
Title or Position: OWNER
Credential:
Phone: 708-243-1169