Healthcare Provider Details

I. General information

NPI: 1295412518
Provider Name (Legal Business Name): LISA MARIE MCDORMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2023
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

282 KARST CIR
SOUTH BLOOMFIELD OH
43103-2525
US

IV. Provider business mailing address

282 KARST CIR
SOUTH BLOOMFIELD OH
43103-2525
US

V. Phone/Fax

Practice location:
  • Phone: 614-420-1850
  • Fax:
Mailing address:
  • Phone: 614-420-1850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: