Healthcare Provider Details

I. General information

NPI: 1477955409
Provider Name (Legal Business Name): LISA RENEE BAIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2014
Last Update Date: 09/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 N PRICE LN
CLINTON MO
64735-1721
US

IV. Provider business mailing address

905 N PRICE LN
CLINTON MO
64735-1721
US

V. Phone/Fax

Practice location:
  • Phone: 660-885-1095
  • Fax: 660-885-1095
Mailing address:
  • Phone: 660-885-1095
  • Fax: 660-885-1095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: